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CLINICAL LECTURES 

ON 

INFANT FEEDING 



"Boston Methods 

by 

LEWIS WEBB HILL, M. D. 

}! . 

Junior Assistant Visiting Physician, Children's Hospital, Boston; Alumni 

Assistant in Pediatrics, Harvard Medical School 



Chicago Methods 

by 

JESSE ROBERT GERSTLEY, M.D. 

Instructor in Pediatrics, Northwestern University Medical School; Associate 
Attending Pediatrician, Michael Reese Hospital, Chicago 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1917 






Copyright, 1917, by W. B. Saunders Company 



NOV IO-J9I7 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



©CI.A47S025 



PREFACE 

As these lectures represent a somewhat new method of post- 
graduate medical education in this country, the history leading 
to their development may be of interest. The plan originated 
with Dr. W. S. Rankin, Secretary of the Board of Health of the 
State of North Carolina. He conceived the idea of bringing 
the medical school, in the person of a traveling lecturer, to the 
doors of the physician, enabling the latter in this way to con- 
tinue with his practice instead of being compelled to leave it 
for several months while he sought postgraduate education in 
one of the large medical centers. Upon hearing of this scheme, 
President E. K. Graham, of the University of North Carolina, 
gave it his enthusiastic support, and courses were arranged 
under the joint auspices of the University and the State Board of 
Health. Two sections of six classes each were organized, one 
in the eastern part of the State, one in the western. Each of 
us had six towns in his circuit, and traveled each day to a new 
town, returning to the first one at the beginning of each week. 

One of us was trained in the methods used in Boston, the 
other in Chicago, with postgraduate work in Europe. As a 
result of this dissimilarity in our training the lectures differ a 
good deal, and it occurred to us that it might be of value to 
combine the two sets in one volume, so that the teachings of two 
somewhat different schools of infant feeding may be compared. 

Each of us has prepared and presented his course of lectures 
independently of the other and without knowledge of the other's 
methods and plans. It is with a spirit of cooperation rather 
than rivalry, of construction than destruction, that we offer 
them to the profession. 

Lewis Webb Hill 

Jesse R. Gerstley 
September, 1917 



11 



CONTENTS 



CLINICAL LECTURES ON INFANT FEEDING 
(BOSTON METHODS) 

By LEWIS WEBB HILL, M.D. 

LECTURE I . PAGB 

Introduction to Feeding in General 17 

Breast Feeding 21 

Artificial Feeding 27 

LECTURE II 

The Modification of Milk 31 

LECTURE III 

The Feeding of Normal Infants 41 

The Proprietary Foods 49 

Premature Infants 56 

LECTURE IV 

Difficult Feeding Cases . .' 59 

Disturbances of Digestion 61 

The Various Types of Indigestion 61 

The Stools in Infancy 70 

Constipation 73 

LECTURE V 

Diarrheas of Infancy 76 

Nervous Diarrhea 77 

Mechanical Diarrhea 77 

Fermentative Diarrhea 77 

Infectious Diarrhea 83 

LECTURE VI 

Pyloric Stenosis 91 

Pyloric Spasm 93 

Intussusception 95 

Acidosis 98 

13 



14 CONTENTS 

LECTURE VII page 

Rickets 104 

Scurvy 107 

Spasmophilia Ill 

Clinics 116 

CLINICAL LECTURES ON INFANT FEEDING 
(CHICAGO METHODS) 

By JESSE R. GERSTLEY, M.D. 

LECTURE I 

Introduction 151 

Milk 152 

LECTURE II 

Digestion of Milk 163 

Energy of Foods 176 

LECTURE III 
Modern Conception of Disturbances of Nutrition 178 

LECTURE IV 
Failure to Gain 193 

LECTURE V 
The States of Dyspepsia and Intoxication 205 

LECTURE VI 
Decomposition 224 

LECTURE VII 
Parenteral and Enteral Infections 242 

LECTURE VIII 
Artificial Feeding of the Normal Infant 256 

LECTURE IX 
Breast Feeding 270 

LECTURE X 

Disturbances in the Breast Fed 280 

Clinics 293 

Conclusion 366 



Index 369 



CLINICAL LECTURES 

ON 

INFANT FEEDING 

Boston Methods 

BY 
LEWIS WEBB HILL, M.D. 



CLINICAL LECTURES ON INFANT FEEDING 
(BOSTON METHODS) 



LECTURE I * 
INTRODUCTION TO FEEDING IN GENERAL 

Pediatrics, or the study of diseases of children, is naturally 
divided into a number of sections, of which the most important 
is the feeding of infants and the treatment of the diarrheal dis- 
eases of infancy. 

My lecture today is somewhat of an introductory lecture, 
taking up breast feeding and a short introduction to artificial 
feeding. It is my purpose to make these lectures as practical 
as possible, and to touch upon theory and chemistry only so 
much as is absolutely necessary — as I am fully aware that you 
are a practical group of men, dealing every day with sick people, 
and not with theories, chemical names, and formulae. It is, 
however, necessary for us to consider a few fundamental chemi- 
cal facts upon which modern infant feeding is based before we 
can go on to the more practical portion of the subject. 

I am going to teach you " percentage feeding," which is used 
more in Boston than in any other city. In the old days of infant 
feeding there was no science of any sort ; a little milk and water 
was mixed and fed to the baby, without knowing what he was 
getting of food value; of fat, sugar, and protein. Some babies 
got along very well on this, but as you know some will get along 
on almost anything, whereas some need the utmost care. 

Dr. T. Morgan Rotch, of Boston, about twenty-five years 
ago, devised the so-called percentage method. This means that 
in a baby's milk certain elements have to be recognized. The 

* Sixteen lectures were given in the course. The other nine lectures dealt 
with the general diseases of children. 
2 17 



18 INFANT FEEDING (BOSTON METHODS) 

food elements of milk are, as you know, fat, sugar, and protein, 
and it is desirable to know how much of each the infant is get- 
ting, because digestive disturbances of all sorts are likely to be 
due to too much or too little of one element or the other in the 
milk. These ideas simplify the whole matter of feeding because 
the physician can tell so easily with what he is dealing. There 
is no reason why a baby should not have its milk made up in 
just as accurate a way as a prescription is made up. With adults 
it is not necessary to regulate the food so carefully, because an 
adult's digestion is stronger, and small things will not upset it 
so easily. The percentage method of feeding consists simply in 
writing a prescription for the baby's milk according to the in- 
dications, knowing approximately how much of each food ele- 
ment the prescription contains, the most convenient way of 
expressing the quantity of these elements being in percentages. 
As an introduction, I think I cannot do better than to read a 
few lines written a short time ago by Dr. Ladd, of Boston : 

"Now, whatever our method of making a food for infants, in which milk 
is the basis, we are making a modified milk containing certain percentages 
of the elements. Percentage feeding presupposes that these alterations 
have been made by the physician with design and with a definite knowledge 
of the end-result of his changes. By the old method milk was modified 
quite as much as by modern methods, but with this fundamental difference : 
that the physician had not the slightest conception of the composition of 
his mixture, and hence no check upon his results. Without a knowledge 
of the percentage composition of the milk it is next to impossible to give a 
lucid and intelligent expression of its food value. A mixture expressed as 
so many ounces of cream, milk, lime-water, sugar, and water may exactly 
fulfil the requirements of an individual infant, but unless I can express such 
a formula to a student in percentages or calories, or both, my exposition of 
the principles on which I have acted in prescribing such a formula is vague 
and indefinite. 

"Whatever we may feel about the relative values of fats and sugars and 
proteins, and the proportions best suited to individual conditions, the per- 
centage method of thinking, writing, and prescribing should not and does 
not complicate the question. In fact, it simplifies it enormously, for it 
furnishes us the means for accurate estimation of food values, and only by 
such knowledge can we intelligently check up our results when struggling 
with the problem of adapting a food to the individual requirements of an 
infant. 

"If one will grasp this simple idea of percentage feeding, one will dis- 
abuse one's mind of the conception, so erroneously held, that percentage 
feeding is ultra-scientific, very mathematical, complex, and impractical 
for the average practitioner. 

"I wish to emphasize the fact that the purpose of percentage feeding is, 
on the contrary, to simplify the sometimes very difficult question of finding 



INTRODUCTION TO FEEDING IN GENERAL 19 

a food which the infant will digest and upon which it will gain normally in 
development. The mathematics involved in the calculation of percentages 
are of the simplest — a. mere matter of proportions. If properly presented, 
any one of half a dozen in vogue is easily mastered and perfectly practical. 
It does not matter by whose methods one works to gain this fundamental 
knowledge of how to calculate the percentage elements of the food, so long 
as that method is thoroughly mastered. Some methods are simpler to 
understand than others, and any method requires some study and practice, 
but this hardly offers an excuse for ignorance of the* subject. Any third- 
year medical student may in two hours be taught a practical way of calcu- 
lating percentages and estimating the caloric value of any mixture. Such 
knowledge is rudimentary but fundamental. Any physician who pretends 
to feed scientifically should not shun the task of acquiring this knowledge, 
any more than he should avoid the labor involved in grasping the technic 
of simple surgical or bacteriological procedures, in order to become more 
skilled in the practice of modern medicine. Too much is written of the 
difficulties of these methods of calculation by men who have been too lazy 
or indifferent to learn them; too little has been written about the responsi- 
bility of the physician to master them in order to become a more efficient 
worker along the lines of modern infant feeding." 

That is a very good summing up of the question of percent- 
age feeding. In a nutshell, it is necessary to know, in any milk 
mixture which is being fed to a baby, approximately how much fat, 
how much protein, and how much sugar it contains. 

In order to do this it is necessary to know the composition of 
milk. 

Human milk contains 4 percent of fat, 7 percent of sugar, 
1.6 percent of protein, and about 0.2 percent of salts. Cow's 
milk contains 4 percent of fat, 4.5 percent of sugar, 3.2* percent 
protein, and 0.7 percent salts. Now, different specimens of 
human milk vary a great deal. Different cows' milks also vary 
a great deal, but these are the average figures. 

Besides the quantitative differences, there are also certain 
qualitative differences. The fat in the milk is in the form of an 
emulsion; the sugar, protein, and salts are in solution. The 
globules of fat in cow's milk are much larger than in human milk. 
The sugars are exactly the same. 

In all milks there are two kinds of proteins — casein and al- 
bumin or whey protein. In human milk there is more whey 
protein than casein. The ratio is about three to one. In cow's 
milk there is more casein than whey, and this is one reason why 

* These figures are not absolutely correct, but are near enough for practi- 
cal purposes. 



20 INFANT FEEDING (BOSTON METHODS) 

cow's milk is so much harder to digest, because the casein pro- 
tein is coagulated in the stomach into tough curds. The whey 
protein is not. The salts are qualitatively about the same in 
both milks, the most important being salts of sodium, potas- 
sium, magnesium, calcium, iron, phosphorus, and sulphur. 
The salts are of extreme importance in the nutrition of every 
baby, but we cannot take them into practical quantitative 
consideration in feeding a baby, so let us consider the three 
elements — fat, sugar, and protein. It is very important to 
bear in mind this composition of milk. 

Now I want to run over very briefly the digestion of the 
different food elements. First, the fat — it is not acted upon to 
any great extent in the stomach. Chemically it consists of a 
fatty acid in combination with glycerin, forming a so-called 
" neutral" fat. After leaving the stomach it enters the intes- 
tine, where it is split by the pancreatic juice into glycerin and a 
fatty acid. The fatty acid combines with an alkali in the in- 
testine, forming a "soap." This is acted upon by the bile, 
which emulsifies it, and it is then absorbed. The absorption of 
fat is usually very good. Often 90 or 95 percent of the fat 
taken in will be absorbed by a well baby. In other cases as 
little as 30 or 40 percent will be absorbed, and most of the fat 
will come out in the stool in the form of " soaps." 

The sugar is acted upon very little in the stomach. Milk- 
sugar is what is known as a disaccharid, that is, a complex sugar. 
In the intestine it is split into simpler sugars and absorbed as 
such. The absorption of sugar is usually extremely good, and 
it is very rare to find any in the stools of infants. Sugar may 
sometimes remain in the intestine, and may be broken up by the 
bacteria in the intestine into acids, as acetic acid and butyric 
acid. Fats may also be broken up in this way. 

Next comes protein. Protein is partly digested in the stom- 
ach, where it is coagulated by the gastric juices. Digestion is 
carried on further in the intestine by the pancreatic juice and 
the secretions of the intestine, and the end-products are ab- 
sorbed as salts of the amino-acids. An important point which 
I wish to emphasize is that in the intestine of every infant there 
are always two forces working against each other. That is, the 
end-products from the breaking down of fat and sugar are acid 



INTRODUCTION TO FEEDING IN GENERAL 21 

in reaction; those from the breaking down of protein are alka- 
line in reaction, from the ammonia which is formed. The 
normal reaction of a child's stool is slightly alkaline, slightly 
acid, or neutral, and if there is too great acidity or too great 
alkalinity, trouble results. It is very important to have such a 
balance between the fat and sugar and the protein in the food 
as not to have too great acidity or too great alkalinity in the 
intestine. 

You have all probably heard a good deal of discussion about 
"calories." What is a calorie? Of course, all food is fuel. 
The different elements of food have different fuel value, and we 
measure this fuel value by calories. A calorie is the amount of 
heat that is necessary to raise one liter of water one degree centi- 
grade. This is a " large" calorie, which is the one we use in 
infant feeding. The average baby needs about 50 calories per 
pound of body weight in order to thrive. The different food 
elements. produce different amounts of these calories. Fat pro- 
duces 9.3 calories per gram; protein and sugar each produce 
4.1 calories per gram. 

That covers the bare essentials of the theoretical part of our 
subject, and although it may sound rather complicated and not 
very practical, it is necessary to understand the scientific ground- 
work upon which rests the practical superstructure of our ideas 
of infant feeding. 

BREAST FEEDING 

In regard to breast feeding, it is an axiom that every baby should 
be fed upon the breast if possible. Of course, there are a good 
many women who cannot nurse their babies, but it should be 
insisted upon that every woman who is able should nurse her 
baby through the first year. Breast milk produces the big, 
robust babies, and babies who are breast fed have very little 
chance of developing the gastro-intestinal troubles of various 
sorts which bottle-fed babies are so likely to have, especially in 
the summer. Of course, in some cases a baby must be weaned, 
but these cases are comparatively few. Persist in breast feed- 
ing, and do not take the baby off the breast merely because it perhaps 
vomits once or twice or does not gain on the breast milk. If a 
mother has not enough milk, try to find out why. Look after 



22 INFANT FEEDING (BOSTON METHODS) 

her habits, see that she leads a reasonable, quiet life, that she is 
not worried or nervous about anything, and that she gets a 
proper diet. 

Another thing : sometimes the milk is late in coming into the 
breast. Normally, after a baby is born it comes into the breast 
in from twenty-four to forty-eight hours. Sometimes it is 
delayed for four or five days. However, don't take the baby off 
the breast because the milk is late in coming. 

How is a new-born baby to be fed? It may be put to the 
breast six hours after birth. This may not furnish much nour- 
ishment, but it teaches the baby to suck, and it stimulates the 
breast to produce milk. For the first twenty-four hours the 
baby should be nursed every six hours ; for the next day, every 
four hours; for the first few weeks after that, every two hours. 

There is a great deal of discussion in all the pediatric centers 
about the intervals between nursings, but I really think most of 
the intervals — that is, two, two and one-half, three, or four- 
hour intervals are reasonable. Most normal babies get along 
well on any of those intervals. Personally, I think it is best to 
have a normal baby nursed every two hours during the first 
month ; for the next three months every two and one-half hours ; 
after this, every three hours. It is a good thing to have the 
baby take one bottle a day. This gives the mother more time to 
get out and take exercise than if it has to be nursed every time. 

If the bowels of a new-born baby have not moved well soon 
after birth, it is wise to give a small dose of castor oil, because the 
meconium may undergo decomposition and make the baby ill 
from toxic absorption, so it is important to clean it out artificially 
if it has not cleaned itself out naturally. 

It is important to have the baby nursed regularly, and not 
every time it cries. Have this distinctly understood by the 
mother. If the baby is asleep at the time of nursing, it should 
be waked. It is better to give the baby alternate breasts each 
feeding rather than a little out of one and a little out of the other, 
for if one is used for each nursing it will be emptied, and thus 
stimulated to the production of more milk. 

An average baby will empty the average breast in about fifteen 
minutes; of course this time may vary, but that is usually the 
average. A baby does not take the same amount of milk from a 



INTRODUCTION TO FEEDING IN GENERAL 23 

breast at each nursing, and at some feedings it will take only one 
or two ounces, at others six or seven. This is not very impor- 
tant, however, because most babies get the same amount every 
twenty-four hours. If little is taken at one feeding, it will be 
made up at another. The twenty-four-hour amount is the im- 
portant thing to consider. Sometimes it is important to know 
if a baby is getting enough milk in a day, and the best way to 
learn this is to weigh the child before and after each nursing. 
Take the difference between the weights before and after nurs- 
ing, add them all together, and the result will be the number of 
ounces the baby is getting in a day, as an ounce of milk weighs 
about an ounce. 

It is true that every baby should be fed on the breast, but it is 
also true that there is abnormal breast milk — bad breast milk. 
There are four kinds of bad breast milk. The first kind is too 
rich — it has too much of every food element. This type of 
milk is found in certain women of the upper classes usually, who 
eat too much rich food and who do not take enough exercise. 
The second type is one in which the fat and sugar are low and 
the protein high. This sort of milk is seen in the poorer classes 
of women who do not get enough to eat and who have to work 
too hard. The third type of milk is one in which the fat and 
sugar are very low and the protein very high. This type of 
milk is usually found in excessively neurotic women. The 
fourth type of milk is that in which, by repeated chemical 
analyses, it is found that every one of the elements is in perfect 
proportion ; but which, for some reason or other, the baby can- 
not take. I do not know the cause, but it is unquestionably true 
that in the milk of some nursing women a toxic substance is 
secreted, and this upsets the baby. In one case I analyzed the 
milk three times and found it perfectly normal, but the baby 
could not take it at all and had to be weaned. Of course, in 
considering this type of milk it must be taken into account that 
the trouble may be in the baby and not in the milk, and that the 
milk might be perfectly suitable for some other baby. 

This type of milk is not common, but it is certainly seen some- 
times. It ought not to be assumed, however, that a milk is of 
this sort until the nursing mother has been given a very thorough 
trial and until the milk has been analyzed, if possible. Never 



24 INFANT FEEDING (BOSTON METHODS) 

give up nursing until every means has been tried of modifying 
the mother's milk and making it better. 

How may the chemical composition of a nursing mother's 
milk be modified? 

When a woman has too rich milk, the important things are to 
take her outdoors, — make her exercise, — keep her bowels open, 
cut down on her diet, and make her drink plenty of water. In 
the other type, where the milk is too thin, ease up the woman's 
home life, have her arrange to get some one to do part of her 
work, and have her eat more, especially fatty and starchy food. 
If the quantity of milk, on the other hand, is too little, have her 
drink plenty of fluid. I have many of my nursing mothers take 
corn-meal gruel at night before going to bed. It is of no use, 
however, to give more than three or four pints of fluid a day; 
anything over this does more harm than good. Another thing, 
and probably the most important of all : use the breast. There 
is nothing which will stimulate milk production so well as a com- 
plete emptying at each nursing. If the baby is. weak and small 
and does not empty the breast, pump it out. There is no drug 
with which I am familiar that will increase milk secretion. 

As to the diet of the mother: I think the best thing to tell a 
nursing mother in average circumstances is to eat exactly what 
she would if she had no baby at all, provided she is taking a 
reasonable diet. Undoubtedly there are certain things which 
may be eaten by a nursing mother that will influence the milk 
and upset the baby. Cabbage, strawberries, and certain other 
fruits and vegetables sometimes do this. Babies generally get 
on well, however, if the mother is healthy and eats an average 
ordinary diet. 

How much should a normal breast-fed baby gam? It should 
be weighed every week, so that its progress can be followed, 
and the food corrected, if necessary. The normal breast-fed 
baby should gain six to eight ounces a week for the first five 
months of its life. For the rest of the first year it should gain 
four to six ounces a week. If it does not gain as much as this, 
there is something wrong. The weight of a baby is one of the 
best indices we have to determine whether or not it is thriving, 
and the weighing of babies is neglected in altogether too many 
cases. 



INTRODUCTION TO FEEDING IN GENERAL 25 

The breast-fed baby usually has three or four rather loose, 
golden-yellow, sour-smelling movements a day. Those fed on 
cow's milk usually do not have so many. 

Certain babies may have more than others and the stools may 
be green in color and smell bad. The baby may vomit a little. 
But if it is getting on well in every other way and is gaining 
weight, it is best not to pay too much attention to this. 

Let us take up the abnormal breast-fed baby, the baby who is 
not gaining on the breast, who has a good deal of colic, who does 
not sleep at night, who vomits often, who has bad movements; 
and the thin, poorly nourished, breast-fed baby who does not 
get enough to eat. These troubles may be due to a number of 
causes. If a baby does not gain, but has no symptoms of in- 
digestion, the milk may not be rich enough or there may not be 
enough of it. In cases like this substitute feedings should be 
given after a trial has been made to increase the amount and 
richness of the milk. Modified cow's milk can be given after 
each breast feeding, or it can be substituted in alternate feedings 
with the breast. It is a little better to give it after each breast 
feeding, because cow's milk is better taken care of in the stomach 
when it is mixed with human milk. 

When a baby has colic, when it is fussy most of the time and 
does not gain, the milk is probably too rich, or too much is taken 
at a feeding. It may contain too much fat or protein. The 
sugar in human milk gives very little trouble. The symptoms 
of fat indigestion are vomiting of creamy, thick, sour-smelling 
material, diarrhea, failure to gain, and fussiness. The symp- 
toms of protein indigestion are the same, except that the vomi- 
tus is not quite so thick and creamy. 

Treat these conditions by treating the mother in the first 
place, by taking her outdoors, having her walk, take exercise, 
and by getting her to drink plenty of water. In the second 
place, keep the baby quiet after each nursing. Do not let the 
mother shake it up and down, as so many do. Also, it is a very 
good idea to give a tablespoonful of boiled water to dilute the 
milk. Again, it is well not to let the baby nurse too long. It 
may be getting too much milk. Sometimes if the intervals 
between nursings are increased, it will help these cases. 

As to colic, the treatment is to prevent it, if possible, by regu- 



26 INFANT FEEDING (BOSTON METHODS) 

lating the feeding. The best thing to do during the attacks is to 
give a suds enema, hot applications to the abdomen, half a soda- 
mint tablet, a few drops of gin or aromatic spirits of ammonia, 
or peppermint water. 

A very common cause of disturbance in breast-fed babies is 
irregular feeding intervals. Many mothers nurse their babies 
every time they cry, and thus they are fed sometimes every 
half-hour, sometimes every three hours. Such feeding as this 
is bound to cause trouble; the usual symptoms are failure to 
gain, fussiness and sleeplessness, colic, vomiting, and the passage 
of an increased number of loose stools, which may be green. 
Oftentimes it is surprising to see how much may be done for 
babies of this sort simply by regulating the nursing periods. 

Many babies have the same sort of symptoms because the 
mother is upset or worried about something or because the 
household is in confusion. A nervous mother and a nervous 
household make a nervous and unstable baby, and many babies 
may have severe symptoms of indigestion and may fail to gain 
in weight for a number of weeks until calm and quiet conditions 
are restored in the household. The mother should be in a quiet 
room, without any noise or confusion around if possible, when 
she is nursing her baby; and after the nursing, it should be put 
into its bed and left alone for half an hour. Some babies may 
swallow a good deal of air when they nurse, and with these 
babies it is a good idea for the mother to interrupt the nursing 
every two or three minutes and hold the baby up against her 
shoulder, slapping its back gently, to give it a chance to get rid 
of this swallowed air, which may cause colic. 

There are certain indications for weaning. Many mothers 
have the idea that if menstruation starts the baby should 
be weaned. This is not so. Sometimes menstruation in the 
mother does upset the baby temporarily, but it will probably be 
right again in a day or two. If a nursing mother becomes 
pregnant, however, the baby should be weaned immediately 
in most cases. Women with any wasting disease, such as tu- 
berculosis, cancer, or chronic nephritis, in most cases should not 
be. allowed to nurse their babies. It is also best to wean the 
baby if the mother develops any severe acute illness, such as 
typhoid fever or pneumonia. If the mother has a "cold" or 



INTRODUCTION TO FEEDING IN GENERAL 27 

slight tonsillitis, it is best to discontinue nursing for a day or 
two, or perhaps in some cases not to discontinue it entirely, but 
to substitute bottle feedings for half of the breast feedings. 

If a mother cannot nurse her baby, it is often a very great 
advantage to get a wet-nurse. What are the qualifications of a 
wet-nurse? In the first place, how is the wet-nurse's own 
baby? If it is doing well, the chances are that the other baby 
will do well. No one should be taken whose own baby is over 
eight or nine months old, because after this period the milk 
becomes thin and poor in quality. Every nurse should have 
a thorough physical examination to exclude tuberculosis and 
syphilis. A Wassermann should be done on the blood of every 
wet-nurse if possible. 

ARTIFICIAL FEEDING 

In artificial feeding, what kind of milk is to be used? There 
is another axiom in pediatrics, and that is that no milk is too 
good for a baby. Get the very best milk possible. Get it from a 
good dairy, from a farmer who takes care of his barns and his 
cattle and who is interested in producing good milk. There is 
nothing that causes so many babies to die as unclean milk. 
Milk is really one of the dirtiest things in the world, because of 
the conditions under which it is produced and the ease with 
which bacteria grow in it. 

A handful of dirt may be thrown into a bottle of milk and it 
cannot be seen. What looks like clean milk may be centrifuged 
and a large amount of dirt may be found as a sediment. An 
Ayrshire, Holstein, or plain ordinary "cow" is usually the best 
cow from which to procure the baby's milk. Many of the laity 
prefer a Jersey, but Jersey milk is too rich. The fat may often 
run up to 6 or 7 percent, and the baby may get into a great deal 
of trouble on account of this high fat percentage. 

A baby may be fed on raw milk or on pasteurized or sterilized 
milk. I have no hesitation in saying that every milk fed o a 
baby should be pasteurized or sterilized, especially in a warm 
climate like this, unless it is what is called " certified" milk. 
Certified milk composes less than 1 percent of the milk supply 
of great cities. It is produced under the greatest precautions. 
The cow is washed off before milking, the milkers wear white 



28 INFANT FEEDING (BOSTON METHODS) 

gloves, the barns are sanitary, and every possible precaution is 
taken to produce good milk. But, of course, such milk is only 
a very small proportion of the milk supply, and the milk that 
babies get should in practically all cases be sterilized or pas- 
teurized. Insist upon this. I do not know much about the 
milk supply of North Carolina, but I think it would be a great 
deal better if it were pasteurized or sterilized before being fed 
to babies, and I hope that you will all feed all your babies on 
pasteurized or sterilized milk this summer. 

There has been a great deal of objection to pasteurized milk 
because some people think it is harder to digest. This is not so. 
Some people say that it tends to constipate the baby. But 
what if it does? A slight amount of constipation is better than 
dysentery. Some people say, too, that it is too much work to 
pasteurize milk, but it is really not very much more trouble. 
The greatest objection is that pasteurized and, more especially, 
sterilized milk may produce scurvy; but this is not much of an 
objection. Scurvy can be cured in a few days by the use of 
orange-juice, and it can be prevented by the use of two table- 
spoonfuls of orange-juice a day. In Boston nearly all milk fed 
to babies is pasteurized except the certified milk. The latter 
costs twenty cents a quart, and is therefore out of the question 
for most people. Pasteurization is not an excuse for bad milk. 
Milk, whether pasteurized or not, should be good milk to start 
with, if possible. 

What is the difference between pasteurization and steriliza- 
tion? They are two different processes. Pasteurization con- 
sists of heating milk to 145° F. and keeping it at that tempera- 
ture for thirty minutes. This does not kill the ferments in the 
milk, but it does kill almost all the bacteria except the spore- 
bearing bacteria, of which the gas bacillus is the most important. 
Sterilizing milk, on the other hand, consists in boiling it, which 
kills all the bacteria. 

A great many devices for pasteurizing milk have been put on 
the market, which are convenient, but not at all necessary. 
Milk may be very efficiently pasteurized with a simple home- 
made apparatus as follows: 

Put the milk bottles and some warm water into an ordinary 
tin pail and heat until the temperature of the water is 145° F. 



INTRODUCTION TO FEEDING IN GENERAL 29 

Then take the pail off the stove, put a small doubled-up blanket 
over it, and let it stand for half an hour. Pour off the hot 
water and fill the pail with cold water in order to cool the milk 
as quickly as possible, as spores develop very readily in luke- 
warm milk. 

Sterilization consists in boiling the milk for four or five min- 
utes. Whether or not sterilization or pasteurization should be 
employed depends largely upon the sort of people one is dealing 
with. If they will take the trouble to do it, pasteurization is 
better. 

If a baby is fed on pasteurized or sterilized milk, it should be 
given orange-juice as a prophylactic against scurvy. The best 
way to give this is in two doses, a tablespoonful morning and 
night. It is best given about an hour before feeding. 

I have mentioned a number of times the " modification " of 
milk. Just how is milk to be modified? The modification of 
milk consists in adding water or other substances to cow's milk 
to change it to suit the digestion of the individual baby that is 
being treated. What is of the utmost importance to remember 
is to fit the milk to the individual baby. There are no definite 
rules or laws that can be laid down, because babies vary so much 
in what they will take and in their digestive capacities, but there 
are certain broad principles which may be followed in a general 
way. 

There is no question but that the average practitioner feels 
helpless when it is a question of milk modification, and the 
reason for it is this. Every man who writes a text-book of 
pediatrics has a different method of milk modification, and 
usually gives complicated formulae and long tables which he 
himself understands perfectly, but which are usually hopeless 
for the average practitioner to carry in his mind. Thus great 
confusion has arisen: there are so many different methods. I 
feel very strongly that tables showing how much milk, water, 
etc., should be mixed to feed a baby of a given age should be used 
as little as possible. In the methods I am going to teach you 
one remembers about what percentages should be fed to a baby 
of a given age ; then he figures by the aid of certain data which 
can be easily carried in the head the amounts of milk, cream, 
water, and sugar to use to make up the desired formula. Thus 
multitudinous formulae and tables are largely done away with. 



30 INFANT FEEDING (BOSTON METHODS) 

I am going to teach you two slightly different methods of modi- 
fying milk, which I am sure you will find very simple of applica- 
tion: the " gravity" cream and skimmed-milk method and the 
" whole" milk dilution method. 

Top or " gravity" cream is all the cream that is visible in a 
quart of milk in an ordinary milk bottle after the milk has stood 
for about six hours. It is usually about six ounces of cream, 
and the composition is about 16 percent fat, 4.5 percent sugar, 
3.2 percent protein. There are various methods of taking off 
this cream, which we will discuss later. What is left behind, 
after taking it off, is skimmed milk, which consists of no fat, 
4.5 percent sugar, 3.2 percent protein. These figures are not 
exact, but they are what we use in calculating our milks. The 
skimmed milk, cream, water, and sugar are mixed in such pro- 
portions as to secure the percentages of food elements that are 
desired to feed the baby. 

The other method of modifying milk consists in diluting whole 
milk with water and adding milk-sugar to secure the desired 
percentages. This method of whole milk dilution has one dis- 
advantage, which is that if the milk is diluted enough to reduce 
the protein percentage to the amount which the baby can digest 
the fat is reduced too much, and the food does not contain a 
sufficient number of calories for the baby's nutrition. How- 
ever, a great many babies do very well on this method, but 
others do not. Most normal babies will do perfectly well on 
whole milk and water dilutions, but not many difficult feeding 
cases can be fed by this method. In each case the circumstances 
and the people have to be sized up. Some people will not take the 
trouble to take off the cream and to go through the various steps 
in a cream and skimmed-milk modification. The other method 
is easier, and if I am dealing with ignorant people I tell them to 
use this method of whole milk dilution. 

In feeding a baby, six things have to be decided : 

1. What percentages of the food elements is it to take? 

2. How much food is to be given in the twenty-four hours? 

3. How much food at each feeding? 

4. How often are the feedings? 

5. What method of milk modification is to be used? 

6. How many calories is the baby getting? Does the food 
prescribed furnish enough calories to make it gain weight? 



LECTURE H 

THE MODIFICATION OF MILK 

As an introduction to the lecture today, which deals with the 
modification of milk and the calculation of percentages and 
calories, I can do no better than to quote some words of Dr. 
John Lovett Morse, of Boston: 

"In approaching the subject of artificial feeding, it must be remembered 
that there are only a few food elements. A baby's food may contain all 
these elements; it must contain some of them, it cannot contain any other 
elements. These food elements are fat, carbohydrate, protein, and salts. 
It must also be remembered that a baby, in order to thrive and gain, must 
have a sufficient amount of food. The amount of food, in considering its 
fuel value, is not calculated, however, in ounces or pints of food, but in food 
values or calories. A baby must receive a sufficient number of calories in 
proportion to its body weight, otherwise it cannot gain. It is not sufficient, 
however, for a food to contain a sufficient number of calories; it must also 
contain a sufficient amount of protein to cover the nitrogenous needs of the 
baby. It must further be remembered that a food may contain enough 
calories and enough protein to cover the caloric and protein needs of the 
baby, and yet not be a suitable food for any baby, or if suitable for one baby, 
not for another. 

"It is absolutely necessary to fit the food to the digestive capacity of the 
individual infant. These fundamental principles must be always borne in 
mind in feeding babies artificially. If they are forgotten, the result is 
likely to be failure rather than success." 

You will remember that I said at our last lecture that there 
were two methods of milk modification we were going to con- 
sider : 

1. The " gravity" cream and skimmed-milk method. 

2. The " whole" milk dilution method. 

I also said that there is more trouble to the first method, but 
that it is likely to give better results in difficult feeding cases, 
and that the second method is a good deal simpler to use and 
more applicable for most patients, especially when they are not 
intelligent enough to carry out the first method. 

Gentlemen, I know that the figures and formulas we are going 

31 



32 INFANT FEEDING (BOSTON METHODS) 

to talk about may seem complicated to you, but I want to say 
now, before we go any further, that infant feeding is fussy, and 
that if a man wishes to have any success whatever with it he 
must be willing to go into considerable detail and take as much 
pains with his feeding cases as he would take with the most 
difficult surgical or obstetrical case. 

First, let us consider the gravity cream and skimmed- 
milk method. Gravity cream is all the cream that is visible 
on a quart bottle of milk that has stood about six hours. 
This amounts usually, in an average milk, to about 6 ounces. 
Skimmed milk is what is left behind after the gravity cream has 
been removed. 

Gravity cream has the following composition: 

Fat 16.0 percent 

Sugar 4.5 

Protein 3.2 

Skimmed milk has the following composition: 

Fat 0.0 percent 

Sugar 4.5 " 

Protein 3.2 " 

These percentages are not absolutely correct, but are the ones 
we use in our calculations, and for practical purposes are near 
enough. 

I am not going to speak of the way in which to take care of the 
utensils used in milk modification, — you can get this from any 
text-book, — but will merely say that the thing of greatest im- 
portance is to have all utensils as clean as possible. There are a 
number of ways of separating the cream from the skimmed 
milk, the most practical of which are pouring and dipping. 
Pouring is the simpler, but not very accurate, and if one is deal- 
ing with a family who will take the trouble, it is best to have 
them remove the cream with a small dipper. The dipper de- 
vised by Dr. Chapin, of New York, and known as the "Chapin 
dipper," is the best, and can be obtained at most drug-stores. 

Now suppose we want to prepare a certain formula, let us say : 

Fat 3 percent 

Sugar 6 " 

Protein 2 



THE MODIFICATION OF MILK 33 

The amount to be 32 ounces, and the lime-water in the mixture 
to be 25 percent of the skimmed milk and cream used: how 
much cream do we need? We want 3 percent of fat — all the 
fat is coming from the cream; the fat content of our cream 
is 16 percent, therefore ye" of our mixture will be cream: -jq of 
32 = 6. Therefore 6 ounces cream will go into our mixture. 
How much protein did we put in with the cream? Cream con- 
tains 3.2 percent protein, so if we had made up our complete 
mixture of 32 ounces with cream alone, we would have put in 
3.2 percent protein. But we are putting into our 32-ounce 
mixture only 6 ounces of cream. Therefore we have put in — 
3 6 2 of 3.2 percent = 0.6 percent protein. 

But we want 2 percent of protein in our mixture. We want 
1.4 percent more protein. This is to come from the skimmed 
milk. We want — 

1 4 
-^- of 32 = 14 ounces. 

Then we put into our mixture 14 ounces of skimmed milk, 

giving us so far 20 ounces of cream and milk in all. How much 

sugar did we put in with this cream and skimmed milk? If 

we had put into our 32-ounce mixture 32 ounces of cream and 

skimmed milk, we would have put in 4.5 percent of sugar; but 

we put in only 20 ounces, 

20 
So— of 4.5 = 3 percent sugar. 

We need 3 percent more sugar, as we wanted 6 percent of 
sugar in our formula. The deficit is made up with dry milk- 
sugar. What we want is yfo (3 percent) of 32 ounces. This 
equals 1 ounce. A rounded tablespoon of milk-sugar equals 
Yi ounce. Then we put in two rounded tablespoons of milk- 
sugar. We wanted our lime-water to be 25 percent of the milk 
and cream used. 

25 percent of 20 = 5. 

Then we need 5 ounces of lime-water. 

Gravity cream 6 ounces 

Skimmed milk 14 " 

Lime-water 5 " 

Water 7 " 

Milk-sugar 2 rounded table- 
spoonfuls 



34 INFANT FEEDING (BOSTON METHODS) 

I know that all this seems very complex, but you will not have 
to figure out all your modifications this way, as I can show you 
some short cuts which will simplify matters greatly. It is very 
important, however, to know how to use this long method of 
calculation, even if you do not use it much. The calculation is 
just the same for any formula, and any desired formula may be 
calculated by using this one as a model. The advantage of 
knowing this method of calculation is that no tables whatever 
are necessary : all that is necessary is to remember the percent- 
age composition of the milk and cream and the various steps 
used in the calculation, and when it is once learned, it is not for- 
gotten. / wish to emphasize particularly that not one of you can 
learn to figure formulas by hearing me talk about it: you must 
give the matter a little thought yourselves and take a pencil and paper 
and figure a few. If you are willing to give the matter an hour 
of your time some day, I am sure that you can all learn to calcu- 
late these formulae very quickly and readily, and that you will 
find this of great value in your practice. A great many practi- 
tioners have objected to percentage feeding on the ground that 
the calculation of the formulae is too complicated. It is more a 
question of laziness than anything else; any man can learn 
these methods if he is willing to take a little trouble, but he cer- 
tainly never can learn them by reading this over superficially or 
by hearing some one else talk about them; he must do a little 
thinking for himself. It is often of importance to calculate 
backward; that is, if it is known that a certain number of 
ounces each of skimmed milk, gravity cream, and milk-sugar 
are being used, how can it be determined what percentages are 
being obtained? Let us say we are using this formula: 

Gravity cream 8 ounces 

Skimmed milk 20 " 

Water 20 " 

Milk-sugar 4 

Total mixture equals 48 ounces. 



Then 



¥ \ of 16.0 = 2.6 percent fat 
ff of 3.2 = 1.8 percent protein 

|f of 4.5 = 2.8 percent sugar, went in with the skimmed 
milk and cream 



THE MODIFICATION OF MILK 35 

Four rounded tablespoons (2 ounces) of sugar equal about 4.00 
Then we have, 

Fat, 2.60; sugar, 6.8; protein, 1.8. 

Short Method. — The method of calculation which we have 
been discussing is of value because when it is once learned no 
tables are necessary. But it is rather long ; it is a good deal of 
trouble to go to all this figuring every time a modification is 
prescribed, and it is usually not necessary, for there are certain 
short cuts which simplify matters greatly, and which enable one 
to figure formulae much more quickly than is possible with the 
"long method." There are two simple tables which must be 
remembered if this short method is used, but these are not 
complicated and they can usually be carried in the head. I 
think this short method is the one you will want to use in feeding 
your babies, rather than the long one. It is as follows: 

In a 16-ounce mixture the number of ounces of 16 percent 
(gravity) cream that is needed always equals the fat percentage 
desired, and the number of ounces of skimmed milk and cream 
needed always equals five times the percentage of protein de- 
sired. Thus, let us say that a mixture of 16 ounces is wanted, 
containing: 

Fat 3 percent 

Sugar 6 " 

Protein \fr " 

Then— 

3 ounces of gravity cream is needed 
1.8 (protein percent desired) X 5 = 9 ounces skimmed 
milk and cream 

This means 6 ounces skimmed milk, for 9 — 3 = 6. 

We have put 9 ounces of skimmed milk and cream into a 16- 
ounce mixture : how much sugar have we put in with this? 

T 9 ^ of 4.5 percent of sugar = about 2.5 percent sugar. 

We need 3.5 percent more sugar. How much dry milk-sugar 
are we going to need? This can be very easily calculated from 
the following sugar table, or it can be figured out by ounces, as 
we did in the long method. 



36 INFANT FEEDING (BOSTON METHODS) 

Sugar Table 
One level tablespoon of sugar raises the sugar percentage — 

2.40 percent in a 16-ounce mixture 
2.00 percent in a 20-ounce mixture 
1.60 percent in a 24-ounce mixture 
1.20 percent in a 32-ounce mixture 
1.00 percent in a 40-ounce mixture 

.95 percent in a 42-ounce mixture 

.80 percent in a 48-ounce mixture 

In this 16-ounce mixture we are dealing with we have figured 
that we need 3.5 percent more sugar. Then, dividing 3.5 by 
2.4 to get the number of tablespoons, we get 3.5-^2.4=1.4, or 
about 1J/2 level tablespoons of sugar. Water, of course, is 
added up to 16 ounces. 

This method of calculating simplifies the whole procedure a 
great deal, as you can easily see. The sugar table is easily 
remembered after it has been used a number of times. 

In a 16-ounce mixture, you will remember, the figure to mul- 
tiply the desired fat percentage by to secure the required num- 
ber of ounces of cream is 1, and the number to multiply the 
protein percentage by to secure the number of ounces of milk 
and cream is 5. There are similar figures for different mixtures, 
which are as follows: 

20 ounces: Fat factor, 1.25 Protein factor, 6.2 

24 ounces: Fat factor, 1.50 Protein factor, 7.5 

32 ounces: Fat factor, 2.00 Protein factor, 10.0 

40 ounces: Fat factor, 2.50 Protein factor, 12.5 

42 ounces: Fat factor, 2.60 Protein factor, 13.1 

48 ounces: Fat factor, 3.00 Protein factor, 15.0 

You will see that it is a great deal easier to figure modifications 
by this table than to calculate them by the "long method" 
which I first spoke of, and if a little card is carried in the pocket 
with the different fat and protein factors on it, it is a simple 
matter to figure any modification in a very short time. The 
mixtures most frequently used are 16-, 32-, and 48-ounce mix- 
tures, and it is very easy to remember, without any card, that 
the fat factors are 1, 2, and 3 respectively, for these mixtures, 
and the protein factors 5, 10, and 15. 

This covers the gravity cream and skimmed milk method of 
milk modification. 



THE MODIFICATION OF MILK 37 

Now let us turn to the whole milk method; that is, simple 
dilutions of whole or skimmed milk with water and addition of 
sugar. This is the method which is best to use with people who 
are too ignorant to handle the skimmed milk and cream method, 
and most normal babies will get along fairly well with it. As I 
have said before, its disadvantages are that the fat in the milk is 
usually too much reduced, and it is impossible to secure by this 
method certain combinations of percentages of the food elements 
which can be obtained by the use of the gravity cream and 
skimmed milk method, which might be needed in feeding cer- 
tain abnormal babies. It depends a great deal upon what com- 
bination of percentages is desired whether the gravity cream and 
skimmed milk or the whole milk dilution method should be 
used, and it is simpler, if one can get the percentages one wants 
by it, to use the latter method. 

Also, normal babies over eight or nine months old can be fed 
very well on whole milk dilutions, as what we are driving at at 
this period of the baby's life is to get it gradually onto whole 
milk — and a baby of this age needs comparatively little diluent 
in its milk, so the fat is not reduced too much by dilution. 
These are some of the considerations which should be taken into 
account in the choice of a method. 

In using whole milk dilutions it is best not to say to oneself 
that one wants certain percentages in the formula, and then to 
calculate it out, for in many cases one will have picked out an 
impossible combination of fat and protein percentages. One 
can, of course, obtain any sugar percentage desired (provided it 
is not too low), whether the cream and skimmed milk or the 
whole milk method is used. In using whole milk dilutions 
either one of two procedures may be employed : 

1. Use the desired amounts of milk, water, and sugar, and 
then calculate what the percentages are, so that the modifica- 
tion can be checked and the approximate composition of the 
mixture determined, so that the baby does not get too strong 
or too weak a formula. As a matter of fact, after a person 
has fed babies for a while this way, he knows almost auto- 
matically about what the percentages are in any dilution, and 
does not need to stop and calculate them. It is not accurate or 
at all advisable, except in the case of babies who are nearly on 



38 INFANT FEEDING (BOSTON METHODS) 

whole milk, or in those who have infectious diarrhea, and who 
are being underfed any way, to simply mix milk, water, and 
sugar and pay no attention to the percentages; one is likely to 
get into trouble if this is done, and the percentages should al- 
ways be figured as a check to this method of feeding. Let us 
say that a baby is being fed on whole milk and water dilution, 
and one wants to know what percentages it is getting. Say it is 
taking a 48-ounce mixture: 

Whole milk 36 ounces 

Water 12 " 

Milk-sugar 4 level table- 
spoons 

Then, as whole milk contains: 

Fat 4.0 

Sugar 4.5 

Protein 3.2 

|f of 4.0 = 3.0 percent fat in the mixture 
ff of 4.5 = 3.3 percent sugar in the mixture 
ff of 3.2 = 2.4 percent protein in the mixture 

A level tablespoonful of milk-sugar added to a 48-ounce 
mixture raises the sugar percentage 0.8 percent. Therefore 
the sugar percentage in this mixture has been raised 3.2 percent, 
which, added to the sugar that has already been put in with the 
milk (3.3 percent), gives 5.5 percent sugar in the mixture, and 
the baby is getting — 

Fat 3.0 

Sugar 5.5 

Protein 2.4 

The same method is used in figuring any whole or skimmed 
milk and water dilution. 

2. Another way that one can use whole milk dilutions is with 
the aid of a table, which is perhaps easier. In any whole milk 
and water mixture if t& of the mixture is milk, that is, 5 
ounces milk in a 16-ounce mixture, and the rest water, the per- 
centages are: 

Fat 1.25 

Sugar 1.40 

Protein 1.00 



THE MODIFICATION OF MILK 39 

Similarly, if more milk is added: 



8 

1 2 
T6 



Fat 1.50 


Sugar 1.70 


Protein 1.20 


Fat 1.75 


Sugar 2.00 


Protein 1.40 


Fat 2.00 


Sugar 2.25 


Protein 1.60 


Fat 2.25 


Sugar 2.50 


Protein 1.80 


Fat 2.50 


Sugar 2.80 


Protein 2.00 


Fat 2.75 


Sugar 3.00 


Protein 2.20 


Fat 3.00 


Sugar 3.30 


Protein 2.40 



The amount of sugar necessary to add can be determined by 
referring to the sugar table given above, which I will repeat 
again for the sake of clearness : 

One level tablespoonful of sugar raises the sugar percentage — 

2.40 in a 16-ounce mixture 
2.00 in a 20-ounce mixture 
1.60 in a 24-ounce mixture 
1.20 in a 32-ounce mixture 
1.00 in a 40-ounce mixture 

.95 in a 42-ounce mixture 

.80. in a 48-ounce mixture 

The table of whole milk dilutions is calculated on the basis of 
sixteenths. Of course, if one is dealing with a 32-ounce or a 
48-ounce mixture, the fraction tV or yV, etc., is multiplied 
through by 2 or 3, as the case may be; that is, tw is the same as 

1 0. nr 15 

32 or 48 . 

Proportionate calculations can be made for 24-ounce or 40- 
ounce formulae, that is, in a 24-ounce mixture the amount of 
each ingredient would be f times what it would be for a 16-ounce 
mixture, or in a 40-ounce mixture it would be f what it would be 
for a 32-ounce mixture. Thus we can accurately figure from 
this table 16-, 24-, 32-, 40-, and 48-ounce mixtures, which are 
the most common ones used. 

So much for the calculation of percentages. The " whole 
milk" method is considerably simpler to use than the gravity 
cream and skimmed-milk method, and it will probably be the 
more practical one for you gentlemen to use most of the time in 
feeding many of your normal babies. 

Now for the calculation of the calories. There may be very 
accurately calculated percentages of the food elements in the 
mixture, but if the baby is not getting enough to eat, they do not 
do him much good. Most babies require about 50 calories per 



40 INFANT FEEDING (BOSTON METHODS) 

pound of body weight in order to thrive. This varies a good 
deal, of course, in different babies. If a baby is gaining weight 
steadily and is doing well, there is not much use in calculating 
the calories in its food. It is self-evident that it is getting enough 
to eat from the simple fact that it is gaining weight. If it is 
not gaining, however, or if the weekly gains are too small, it is 
advisable to calculate the caloric value of the food, and it can be 
done very easily by the following simple formula: 

(2F + P + S) X 1M Q = total calories 

F = The fat percentage of the food 

P = The protein percentage of the food 

S = The sugar percentage of the food 

Q = The twenty-four-hour quantity of the food 

To a man who has not been brought up in the method the use 
of so many figures and calculations may seem extremely compli- 
cated; but, as I have said before, the feeding of a baby who is 
not doing well is a very delicate task, which requires a great 
deal of painstaking care, and much time and thought must be 
given to it if good results are to be obtained. I am perfectly 
sure that after you have used these methods for a while you will 
have no trouble whatever with them. 

I wish to emphasize particularly that in using the percentage 
method it is not necessary to calculate the percentages too accurately, 
for any chain is only as strong as its weakest link, and it is non- 
sensical to try to get greater accuracy in the calculating than there 
is in the percentage of the milk to start with, or in the methods of 
mixing it. 

The idea of great accuracy in calculation is one that has been 
a stumbling-block to many beginners in percentage feeding. 
At the next lecture we will take up the feeding of the premature 
and normal baby and a discussion of the various proprietary 
foods. 



LECTURE m 

THE FEEDING OF NORMAL INFANTS -THE PROPRIE- 
TARY FOODS -PREMATURE INFANTS 

THE FEEDING OF NORMAL INFANTS 

I am going to take up today the feeding of normal babies and 
children, then a discussion of the various proprietary foods, 
showing their advantages and disadvantages. After that, if 
there is time, I shall discuss the care and feeding of premature 
infants. 

Breast milk contains 4 percent fat, 7 percent sugar, 1.6 per- 
cent protein — a food relatively rich in fat and sugar and poor 
in protein. It is reasonable to suppose that as this is the type 
of food nature intended for infants, the best artificial food for 
them is a food which somewhat approximates breast milk in its 
composition, and in which, especially, the proportion of one ele- 
ment to another is somewhat the same as it is in breast milk. 

We do not try to exactly imitate breast milk, however. Rather do 
we try to fit the milk to the digestive capacity of the individual baby, 
determining this capacity by watching the baby's symptoms, its 
weight, and by carefully examining its stools. 

The feeding of any baby is more or less experimental for the 
first few feedings. The digestive capacity of average babies of 
similar size, age, and weight is known; but the digestion of any 
particular baby is at first an unknown quantity, until the physi- 
cian becomes better acquainted with it, so the baby is given a 
milk which it ought to be able to take, and if it cannot digest 
that, the food has to be altered to suit the capacity of its diges- 
tion. It is very important in all artificial feeding to fit the food 
to the baby. The baby, and not rules and tables, ought to be 
followed in artificial feeding. Remember the individual baby 
and certain broad general principles which apply to all babies. 

The feeding of sick babies is a different proposition from feed- 
ing well babies. Often a sick baby cannot take a milk that is 

41 



42 



INFANT FEEDING (BOSTON METHODS) 



anything like the milk a well baby would take. More than 
ever, dealing with these abnormal cases, does the food have to be 
fitted to the particular digestive and absorptive power of the 
individual baby. 

How often is a baby to be fed, how strong a food is it to take, 
how much of it in the twenty-four hours, and how much at each 
feeding? 

As I said last time, this varies a great deal for different babies. 
Two babies of the same age, size, and weight may take entirely 
different amounts and strengths of food and may need entirely 
different intervals. Especially is it true that two babies of the 
same size and weight, but of different ages, will need different 
foods. The older baby will need a great deal more food and 
stronger food than the younger baby. In general, an older baby 
needs more calories per pound of body weight than a younger 
baby of the same size and weight. 

Now, if we were feeding a baby rather small amounts of food, 
we would naturally give these small amounts more often. If 
a large feeding is given each time, the intervals should be 
lengthened. This table shows what most well babies will take 
and the most usual intervals employed : 



Age 
1 wk. . 

4 wks. 

4 mos. 

6mos. 
9 mos. 



Twenty-four- 
hour Amount 

10-12 ounces 

20 " 

32 " 

36-42 " 
48 " 



Number of Feedings, Amount and 
Intervals 

10 feedings of 1 ounce every 2 hours 



" \ X A ounces 


' 2V 2 < 


" 2^ " 


1 2V 2 ' 


u 3 u 


1 3 


« 4 


1 23^ '- 


" 4M " 


' 3 


« 6-7 " 


' 3 


it 8 


' 3 



(From Morse and Talbot's "Infant Feeding.") 



Composition of Food 

Age Fat Sugar 

First food 1.00 5.00 

First week 2.00 6.00 

1 month 3.00 7.00 

2 months 3.00 7.00 

4 months 3.00 7.00 

6 months 3.50 7.00 

8 months 4.00 7.00 

lyear 4.00 4.50 



Protein 
0.50 
0.75 
1.20 
1.60 
1.80 
2.25 
2.50 
3.20 (whole milk) 



THE FEEDING OF NORMAL INFANTS 43 

As to night feedings, most babies, or at least a great many 
babies over four or five months old, will get along without 
any, taking their feedings from six in the morning to nine 
or ten at night, and going through the night without any feed- 
ing until the next morning. In general it is a bad plan to allow 
the baby to take two or three night feedings unless there is 
some special indication. If the baby is atrophic and not doing 
well, of course it will probably have to be fed through the night. 
But it is a good plan to do away with the night feeding if pos- 
sible, because it saves so much trouble to the parents, and most 
babies can get along without any, or if they require it at all, they 
can get along with one feeding instead of two or three. 

Let us take up again the different elements of the food. First, 
let us consider the fat. It is always unwise to feed any baby, 
no matter how old, on more than 4 percent of fat. That is the 
limit of fat tolerance for practically every baby. Most babies 
will not be able to take even this amount. Most of them, until 
seven or eight months of age, will get along better on 3 percent 
than on 4. Some babies will get. along better on 2 percent than 
on 3. 

The fat in the milk causes more trouble than any other ele- 
ment. More babies have chronic nutritional disturbances from 
a difficulty of fat absorption than from any other cause. 

It is important to consider what percent cream is being used 
in making up the modification if the gravity cream and skimmed- 
milk method is used. It is not, of course, correct to use a 32 or 
20 percent cream, and calculate as though it were a 16 percent 
cream, because the baby may be getting in this way 6 or 7 per- 
cent of fat when the feeding is supposed to contain only 3 or 
4 percent. In calculating fat percentages it is well not to give 
any baby over 3 percent of fat when using the gravity cream 
and skimmed-milk method of modification, because the skimmed 
milk inevitably contains a small amount of fat, and the fat per- 
centage will be higher, in using this method, than the calcula- 
tion shows. 

Also, throughout this particular district of North Carolina 
there seem to be a great many Jersey cows, or cows of part 
Jersey blood. It must always be remembered that Jersey milk 
is richer in fat than other milks are, and for this reason, if the 



44 INFANT FEEDING (BOSTON METHODS) 

milk of a Jersey cow has to be used, it is well to remove part of 
the cream before making up the milk modification. The milk 
from a mixed herd is likely to be much more uniform in compo- 
sition than is the milk from one cow, and this is why it is usually 
best to feed a baby on milk from a mixed herd, if it can be ob- 
tained. 

Some babies who cannot take milk-fat well are able to take 
olive oil, and in such cases it is well to give a teaspoonful of 
olive oil three or four times a day rather than, give so much fat 
in the milk. Rubbing the baby with oil does not do much good, 
because there is practically no absorption through the skin. 
This merely keeps the skin in good condition and does not act 
as a food for the baby. 

Recently there has come into use what is called homogenized 
milk. It is made by intimately mixing olive oil and skimmed 
milk by forcing them through a valve under considerable pres- 
sure. The oil-globules are broken up and made very small, 
and this milk is often much better digested than any other in 
certain cases of chronic fat indigestion, where the baby cannot 
take the milk-fat. I am sure this milk will be available to every- 
body in a few years, but it is not at present, so this, for you 
gentlemen, now is a matter of theoretical interest rather than 
of practical importance. 

Let us consider next the sugar. There are a number of differ- 
ent sorts of sugar. There are lactose, or milk-sugar; sucrose, 
or cane-sugar; and maltose, or malt-sugar. These are the three 
sugars used in practical infant feeding. Ordinary lactose, or 
milk-sugar, is the best for feeding most normal babies. It may 
be split up in the intestine into acids, and when it ferments, is 
likely to be rather laxative. Sucrose has ordinarily no advan- 
tage over lactose except that it is cheaper. Generally it is 
better not to feed babies on sucrose if one of the other sugars is 
available. 

Maltose is never given pure. Pure malt-sugar is very ex- 
pensive and hard to obtain. Malt-sugars and the various malted 
foods consist of part dextrins and part malt-sugar. Some of 
these preparations which we must consider are as follows : 



THE FEEDING OF NORMAL INFANTS 45 

Composition 
Maltose Dextrins 

Meade's Dextri-maltose 51 percent 47 percent 

Mellin'sFood 58 " 20 " 

Maltine Malt Soup 62 " 3 " 

Loeflund's Malt Soup Extract . . 59 " 15 " 

Maltose is more readily absorbed than lactose, and its as- 
similation limit is higher ; that is, a baby can take more maltose 
without showing sugar in the urine than it can lactose or sucrose. 
Malt-sugar ferments less readily than does lactose, and for this 
reason a malt-sugar preparation is often of value in feeding 
certain cases of sugar indigestion or fermentative diarrhea. 
Malt-sugar is also ordinarily the best sugar to use in feeding 
cases of convalescent infectious diarrhea. All the malt-sugar 
preparations consist of combinations of maltose and dextrins. 
If the proportion of maltose is high in comparison with the dex- 
trins, the food is likely to be laxative; if the proportion of 
dextrins is relatively high, it is likely to be constipating. Dextri- 
maltose, on account of its high content of dextrins, is somewhat 
constipating; the other malt-sugar preparations are laxative. 
The various malt-sugar preparations are of unquestionable 
value in feeding certain cases; but two things must be remem- 
bered about them: 

1. Some babies may have an idiosyncrasy to maltose and not 
be able to take it at all well, so it is by no means a universal 
panacea for all sugar troubles, as a good many people seem to 
think. 

2. It is to be distinctly remembered that none of the malt-sugar 
preparations or "malted foods" are complete foods, and that their 
proper role in infant feeding is simply as sugars, as substitutes for 
lactose — when substitution of a malt-sugar is indicated. 

Now let us take up starch. It has been proved a good many 
times that new-born babies can digest starch, but they should 
not ordinarily be fed this, because in practical use starch in any 
considerable quantity does not agree with them. I always start 
giving barley water in the milk when the baby is about six or 
seven months old. It furnishes a little extra nourishment, it 
teaches the baby how to digest starch, and aids in the digestion 
of milk casein by tending to prevent the formation of large curds. 
Any one of the ordinary barley flour preparations on the market 



46 INFANT FEEDING (BOSTON METHODS) 

may be used. A tablespoonful to a pint of water gives a 1.5 
percent suspension of starch. The best amount to use is ordi- 
narily about 0.75 percent starch in the milk mixture, as it has 
been found that this is the optimum amount to prevent the for- 
mation of large casein curds. 

" Barley jelly" is of very great value in infant feeding; it 
consists merely of a thick barley gruel, and may be prepared 
as follows: 

Add four tablespoonfuls of barley flour to a pint of water; 
cook in a double boiler one hour, strain to get rid of lumps; add 
enough water to make up to a pint again, salt to taste, and set 
on ice. The resulting product is a very thick gruel, and is fed 
to babies eleven or twelve months old. It is especially of use 
as the first semisolid food after infectious diarrhea. 

" Oatmeal jelly" is also of considerable value, especially in 
feeding 'constipated babies over a year old. It is prepared as 
follows: 

Oatmeal, 4 ounces; water, 1 pint. Boil four hours in a 
double boiler. Add water to form a thin paste. Force through 
a colander while still hot to get rid of coarse particles, and salt 
to taste. 

The protein in the milk is very important because it is a tissue 
builder. It keeps the baby's body in a state of nitrogenous 
equilibrium, and every baby has to have it to keep well. The 
chief trouble with the protein in cow's milk is that it forms large 
curds in the stomach which are hard to digest. Generally the 
protein in the milk causes very little trouble, as it is always 
easy to modify it in such a way that no tough curds will be 
formed in the stomach. 

One way to do this is to give whey mixtures instead of casein 
mixtures. Whey has this composition: 

Fat 0.0 percent Sugar 4.5 percent Protein 0.9 percent 

and all the protein is in the form of "whey" protein, which is 
very easily digested and is not coagulated in the stomach. So 
if a baby vomits and does not digest fat and protein well, whey 
may be used, and most babies can easily digest it. A good many 
babies are able to take whey when they cannot take anything 
else; but it should be remembered that whey is a very weak 



THE FEEDING OF NORMAL INFANTS 47 

food and furnishes little nourishment to the baby, so is of value 
only as a temporary and not as a permanent food. If it is de- 
sired to increase the food value of whey, fat may be added to it 
in the form of 16 percent cream. 

Whey is prepared as follows: To one pint of lukewarm milk 
add two teaspoons of Fairchild's essence of pepsin; stir and mix. 
Let it stand until the milk has "jellied," and then beat it with 
a fork to separate the curd into fine particles. Strain — best 
through cheese-cloth. The liquid which comes through is the 
whey. One quart of milk furnishes about 24 ounces of whey. 

Some of the other methods for preventing the formation of 
large curds are as follows: 

1. Addition of cereal diluents. 

2. Boiling. 

3. Peptonization. 

4. Addition of alkalis. 

1. The addition of a cooked starch preparation, such as barley 
water, to a milk modification, tends to prevent the formation of 
large tough curds in the stomach. About 0.75 percent of starch 
in a mixture is enough to give this action. 

2. Boiling vigorously for five or six minutes produces certain 
chemical changes, which to a considerable extent prevent coagu- 
lation. 

3. Peptonization of milk prevents the formation of a curd in 
the stomach, and also, to a certain extent, predigests the milk. 
Milk should always be peptonized when being fed by rectum, 
but usually it is not necessary to peptonize milk for ordinary 
feeding, because there are so many easier ways of preventing 
curd formation. 

4. The addition of an alkali, in sufficient amount, to the milk 
prevents curd formation. The alkalis which may be used are: 

Lime-water. 

Sodium citrate. 

Sodium bicarbonate. 
For practical purposes lime-water is the best alkali to use, 
although there is certain evidence to show that the use of lime- 
water interferes somewhat with fat absorption, and in cases 
where the fat assimilation is poor, it should probably not be 
given. 



48 INFANT FEEDING (BOSTON METHODS) 

Lime-water must be given in a strength of from 25 to 50 per- 
cent of the milk or milk and cream used in the mixture, if it is 
to have any appreciable effect. The giving of small amounts of 
lime-water does no good. 

Sodium citrate is a valuable alkali to use to prevent curd for- 
mation. Two grains of the citrate to one ounce of milk, or milk 
and cream, is the amount ordinarily used. 

Sodium bicarbonate is used in the same strength as sodium 
citrate, but has this disadvantage: it tends to upset the baby's 
stomach and may cause it to vomit. 

I want to speak briefly of "Eiweiss," or protein milk, of which 
you have all probably heard. The Germans devised this milk 
a few years ago, in order to get a milk with a relatively high 
protein and low fat and sugar content for use in fermentative 
diarrhea. It works very well. The great trouble is that it is 
hard to prepare, as you will see from the directions given below, 
and many people cannot do it satisfactorily. 

One quart of whole milk is heated to 100° F. Add four 
tablespoons of essence of pepsin, and stir. Let it stand at 100° 
F. until a curd has formed, and strain off the whey from the 
curd. Press the curd through a fine sieve three or four times. 
Add one pint of water to the curd and one pint of buttermilk to 
this mixture. 

For all practical purposes it consists then of a pint of butter- 
milk, a pint of water, and curd from a quart of milk. It contains 
about 2.5 percent fat, *1.5 percent sugar, 3 percent protein. 
It can be used if one is dealing with an intelligent family who 
will take the trouble to make it. 

If the baby does not take fat well, it is best to skim the milk 
used in making the curd. 

There is a product on the market called Larosan which is 
a good deal easier to use than this Eiweiss milk. It is in the 
form of a powder, which can be added to a milk mixture to give a 
high protein percentage. It is a practical thing to use, and a 
great many babies with fermentative diarrhea will do extremely 
well on it. The trouble is that the war has interfered with its 
production, and it is now extremely hard to get. 

Let us consider buttermilk for a moment. It has about this 
composition: 1 to 0.5 percent fat, about 3 percent sugar, and 



PROPRIETARY FOODS 49 

about 2.5 percent protein. The protein is in a precipitated 
form, which cannot be coagulated again in the stomach, and 
there is a very low sugar percentage. There is also lactic acid, 
which tends to prevent fermentation or putrefaction. These 
are the advantageous points of buttermilk. Lactic acid bacillus 
or "bulgaricus" cultures are of great value in preparing lactic 
acid milk. I am somewhat skeptical, however, about many of 
the tablets which are put on the market, and do not believe they 
are as efficient as the liquid cultures or as ordinary buttermilk. 
Buttermilk is often of very great value in feeding babies. The 
trouble with it is that it is hard to tell whether or not it is good 
buttermilk. It may be full of all sorts or other bacteria besides 
the lactic acid bacteria. If liquid cultures are used, however, 
and one makes one's own lactic acid milk, one can be sure of 
getting a clean preparation. 

PROPRIETARY FOODS 

The proprietary foods have certain good points and a great 
many bad points. Of course, in certain districts where cow's 
milk cannot be obtained the proprietary foods have to be used; 
but in general the indiscriminate use of proprietary foods has 
done more harm than good, because they are usually prescribed 
without any knowledge whatever of their composition. Most 
of them are of such composition that they do not give a baby a 
well-balanced ration, and may be of value to add to a milk modi- 
fication, but not to use as a complete food. The great trouble with 
most of the proprietary foods is that their sugar content is far 
too high in proportion to the fat and protein content. Most 
babies fed exclusively on condensed milk or on one of the pro- 
prietary foods for any length of time get into trouble sooner or 
later. Proprietary foods cannot contain anything that milk 
cannot contain, and if one knows how to modify milk, anything 
can be put into it that is in any proprietary food. 

I do not mean to give the impression that proprietary foods 
should never be used, for this is not so; but I do mean that if 
they are to be used their composition must be known in order to 
know the amount of each food element the baby is taking, and 
to be sure that it is getting a well-balanced ration. In most of 
4 



50 INFANT FEEDING (BOSTON METHODS) 

the proprietary foods the vitamins are destroyed : these vitam- 
ins are necessary for the baby's proper development. This is 
another reason why it is wrong to feed a baby exclusively on 
condensed milk or any other proprietary food for any length of 
time. 

For many years many people have tried to produce a universal 
infant food which will be a perfect substitute for breast milk and 
which can be fed to any baby. Such a food will never be pro- 
duced; what is food for one baby may be poison for another, 
and any artificial food must always be fitted to the digestive 
capacity of the individual infant. There is no such thing as a 
universal infant food upon which all babies can be fed, except 
breast milk, and there never will be. 

If proprietary foods are used, their composition should be 
known. There are five classes of proprietary foods, which may 
be roughly divided as follows : 

1. Condensed milks and evaporated milks. 

2. Malted foods. 

3. Malted foods containing starch. 

4 Starchy foods, containing practically nothing but starch. 

5. The various "dry milk" powders. 

In class 1 belong the ordinary sweetened, thick condensed 
milks and unsweetened evaporated milks. To the second class 
belong Mellin's Food, Horlick's Malted Milk, etc. (Horlick's 
Malted Milk is not exactly like Mellin's Food in composition, 
as its basis is a dried milk preparation to which considerable 
maltose and dextrins have been added; but in practical use it 
may be considered to be much the same sort of preparation as 
Mellin's Food.) In class 3 is Eskay's Food; in class 4, Ridge's 
Food and Imperial Granum, and in class 5 "Kindolac" is a fair 
representative of the group. 

The condensed milks have all practically the same percentage 
composition. The average composition is about as follows: 

Fat 9 percent Sugar 55 percent Protein 8 percent 

This is a very poorly balanced ration, because there is too 
much sugar for the fat and protein. When the sugar is reduced 
by dilution with water to the proper percentage, the fat and the 
protein are reduced too much, and the baby does not get enough 



PROPRIETARY FOODS 51 

to eat. One part of condensed milk and two parts of water give 
these percentages: 

Fat 3 percent Sugar 18 percent Protein 2.6 percent 

The fat and the protein would be about right in this mixture 
for some babies, but few babies can take 18 percent of sugar for 
any length of time without getting into trouble. If the con- 
densed milk is diluted with four parts of water, this percentage 
results : 

Fat 1.8 percent Sugar 11 percent Protein 1.6 percent 

Condensed milk is usually diluted more, and the dilution I 
have generally seen used is one part of condensed milk to six 
parts of water. That would give a very weak mixture, with 
little nourishment for the baby. With eight parts of water the 
fat would be 1, sugar 6, and protein 0.9. The reason why con- 
densed milk is so much in favor is that a great many babies who 
have been fed on too strong or improperly modified cow's milk 
can take diluted condensed milk simply because it is so dilute 
that it is no tax to their digestions. Still they are not getting 
enough to eat. I have noticed that there is an opinion prevalent 
among many of the laity here that cow's milk is impossible for 
many babies to take, especially in the summer, and that con- 
densed milk is the thing always to give them if they become up- 
set on cow's milk. Of course this is absolutely fallacious; there 
are certain rare cases in which a baby shows an idiosyncrasy to 
cow's milk and can never take it without disturbance, but these 
cases are very, very uncommon, and almost always when a 
mother says "the baby cannot take cow's milk" it is simply 
because the milk has not been modified properly to suit the 
baby's digestion. If cow's milk is modified properly and is 
reasonably clean, most babies can take it as well as they can 
condensed milk or any other proprietary food. Condensed 
milk may be of value occasionally to tide a baby over for a 
few days when a very weak food is desired, but it is absolutely 
unsuitable as a food for any baby whatever over long periods of time. 

The unsweetened evaporated milks have a better composition 
than the condensed milks. The percentage composition of most 
of them is this : 

Fat 9 percent Sugar 10 percent Protein 7 percent 



52 INFANT FEEDING (BOSTON METHODS) 

One part of evaporated milk to three of water gives this per- 
centage : 

Fat 2.25 percent Sugar 2.5 percent Protein 1.7 percent 
A 1 to 4 dilution gives: 

Fat 1.8 percent Sugar 2 percent Protein 1.4 percent 

Milk- or malt-sugar should be added to evaporated milk dilu- 
tions to bring up the sugar percentage. These evaporated 
milks are much better to use than condensed milks, and are 
the preparations to be used if fresh cow's milk cannot be ob- 
tained. 

Horlick's Malted Milk has this composition: 

Fat 9 percent Sugar 67 percent Protein 16 percent 

Its basis is dried milk, to which maltose and dextrins have been 
added. Mellin's Food contains: 

Fat 0.16 percent Sugar 80 percent Protein 10 percent 

These foods are occasionally valuable in infant feeding to 
use as sugars to correct constipation, as the malt-sugar which 
they contain is mildly laxative. It must be remembered that 
they are not. complete foods, and should not be used as such; 
whatever value they have is in their content of maltose and 
dextrins. 

The third class of foods contain a certain amount of starch in 
addition to the other constituents. Eskay's Food is an example 
of this group, and contains 

Fat 3.5 percent Sugar 55 percent Starch 29 percent Protein 6.7 percent 

It is valueless unless used simply as a sugar or starch would be 
used, as an addition to fresh cow's milk, because when it is 
diluted with water the baby gets practically nothing but carbo- 
hydrates. 

Imperial Granum, which belongs to the fourth class, consists 
mostly of starch, part of which has been dextrinized. It may 
be used in the same way that barley flour preparations are 
used. 



PROPRIETARY FOODS 53 

"Kindolac" is a "dried" milk, belonging to the fifth class. 
Its composition is: 

Fat 13 percent Sugar 61 percent Protein 19 percent 

Generally speaking, the trouble with most of the dried milk 
preparations is that they do not contain enough fat, as a high 
fat content interferes with the drying process. So much for a 
few of the proprietary foods. As a brief general summary it is 
fair to say this : 

Most of the proprietary foods do not contain a suitable balance 
of the several food elements to allow them to be used as complete 
foods for any baby; the carbohydrate content is usually high — out 
of all proportion to the fat and sugar. If they are used at all, they 
should be used as substitutes for sugar in the modification of fresh 
milk. It is necessary always in using any proprietary food to 
know approximately its composition. 

When can a baby take solid food? As the first solid food that 
it usually takes is cereal or bread, it is well to add barley water 
to the milk of most babies when they are six or seven months 
old in order to have them get used to starch. When the baby is 
nine months old, it can have a piece of dry toasted bread or 
zwieback to hold in its hand and chew on occasionally. When 
it is ten months old, give it a couple of tablespoonfuls of barley 
jelly or of farina during the day. At a year old the baby should 
be put on four-hourly feeding intervals, at 7, 11, 2, and 6, and 
the twenty-four-hourly quantity of milk should be limited to a 
quart. It is a great mistake to give a baby who is over a year old 
too much milk; at this period of its development it is beginning to 
need solid food, and if too much milk is given, the appetite for solid 
food is likely to be lost. Most babies of eleven or twelve months 
can take whole milk undiluted, and in addition farina or barley 
or oatmeal jelly and zwieback. Chicken or mutton soup (with 
the fat removed), beef -juice, and prune-juice or orange-juice 
may also be given. At about sixteen months most babies can 
begin to take eggs and potatoes. The egg should be soft 
boiled or coddled, and not more than a teaspoonful should be 
given at first, as sometimes eggs cause severe upsets in small 
babies when they first start to take them. It is a bad mistake 
to feed eggs to most babies under fifteen or sixteen months. If the 



54 INFANT FEEDING (BOSTON METHODS) 

baby seems to be able to take the egg well, the amount can be 
gradually increased until it is taking one egg every other day. 
Potato is best given as mashed potato, and this should be well 
mashed, with a good deal of milk added, so that there are no 
large lumps, which almost always go through the baby undi- 
gested. At two years of age a baby can be given finely chopped 
meat: lean beef, chicken, and mutton are the best meats to use. 
At about this same time green vegetables may be given, but it is 
very important to remember that these must be thoroughly 
cooked and mashed or well chopped, so that the indigestible 
cellulose portion will not irritate the baby's intestine. Peas, 
beans, stewed carrots or celery, and asparagus-tips may be given 
in this way. 

As to fruit, I must write it in italics : Green fruit of any sort 
should not be given to any child whatsoever under four years of age. 
There certainly are some babies who seem to be able to eat 
anything and not be upset by it, but for most babies green fruit 
or green vegetables, improperly prepared, are absolutely con- 
traindicated. 

Even after four years of age, and well along into childhood, 
the use of fruits should be considerably restricted, and if they 
are eaten, special care should be taken that no skins, rinds, or 
cores are swallowed. Of course, at about two years a child 
may take a moderate amount of properly prepared stewed fruit, 
such as prunes, peaches, or apricots. Never give any child a 
whole orange; the juice of the orange is good for him, the rest 
of it is not. Small amounts of ripe raw scraped apple are also 
good for some babies as an antiscorbutic when orange-juice 
cannot be obtained. 

The diet list of the Children's Hospital, Boston, for babies of 
about eighteen months, is as follows : 

Milk Milk-toast Baked potato 

Butter Zwieback Plain macaroni 

Mutton broth Plain crackers Orange-juice 

Chicken broth Barley jelly Baked apples 

Beef -juice Oatmeal jelly Stewed prunes 

Soft-boiled eggs Cream of Wheat Baked custard 

Dropped eggs Farina Corn-starch pudding 

Toasted bread Rice Blanc-mange 



PROPRIETARY FOODS 55 

The following diets are taken from that splendid little book of 
Dr. Richard Smith's, "The Baby's First Two Years": 

Diet at Thirteen or Fourteen Months 



6.30-7.00: 


: Strained cereal or gruel, 2 or 3 ounces 




Milk, 8 ounces 


8.30 


: Orange-juice 


10.00-10.30 


: Milk, 8 ounces 




2 zwieback or plain cracker 


1.30-2.00; 


: Broth or beef -juice 




Rice or macaroni or spaghetti 




Bread or toast or cracker 




Milk, 4 to 5 ounces 


5.30: 


: Milk, 8 ounces 




Cereal or gruel 




Apple-sauce or prune- juice 




Diet at Sixteen to Eighteen Months 


7.00: 


Cereal 




Bread and butter 




Milk, 8 ounces 


8.30: 


Orange-juice 


10.00-10.30: 


Milk, 8 ounces 




Cracker or toast 


1.30: 


Egg or beef -juice or scraped beef or minced chicken 




Potato or rice or macaroni or spaghetti 




Bread and butter 




Simple dessert (custard, junket, tapioca) 




Milk, 4 or 5 ounces 




Diet at Twenty to Twenty-two Months 


6.30-7.00: 


Orange- juice 


7.00-7.30: 


Cereal 

Egg 

Bread and butter 






Milk 


10.30: 


Milk 




Cracker or bread 


1.30: 


Meat 




Potato 




Green vegetable (puree) 




Bread and butter 




Simple dessert 


5.30: 


Cereal 




Milk 




Bread and butter * 




Fruit-sauce 



* Bread at least two days old; butter spread very thin. — L. W. H. 



56 INFANT FEEDING (BOSTON METHODS) 



PREMATURE BABIES 

Now I want to talk for a little while about premature babies. 
Two things have to be remembered in dealing with premature 
babies: first, that a premature baby must be kept warm, and 
secondly, its digestion is extraordinarily feeble, so it must be 
given very weak milk mixtures. 

Incubators were formerly thought to be of great value in the 
care of premature babies, but have now been discarded by most 
pediatricians. A small crib, with padded sides to prevent 
drafts, is the best place in which to keep a premature baby. 
There should be a thermometer kept in this crib, and the tem- 
perature should be between 90° and 95° F. ; the rectal tempera- 
ture should be taken two or three times a day to be sure that 
the baby's body-heat is kept up. If the rectal temperature 
varies between 98° and 100° F., there is no cause for any change 
in the heating arrangements. A premature baby should not 
be washed with water, but should be oiled with warm olive oil 
and wrapped in cotton wool or a gown made of cotton wool 
between two layers of very soft cheese-cloth. It is well not to 
use any diapers on a premature baby, but to put a pad of cotton 
wool between its legs, and simply change it when it is dirtied. 
The reason for this is that premature babies bear handling very 
poorly; the less they are handled, the better off they are. 
Don't weigh the baby often — it bothers it too much; once a 
week is enough. Premature babies seem to get along better if 
their air supply is moist, so it is of advantage to keep a little 
alcohol or electric lamp going in the room, with a shallow vessel 
of water over it, to secure the necessary moisture. The tem- 
perature of the room should be about 80° F. A premature 
baby needs reasonably clean air as much as anybody else does, 
so be sure that the room is properly ventilated and not kept 
hermetically sealed to fresh air all the time. 

Get breast milk, if possible, for a premature baby. In most 
cases, of course, it must be obtained from some woman other 
than the mother. If the baby is born at six or seven months, 
the mother probably will not have enough milk, but if the baby 
is born nearly at full term, perhaps she will have. Give the 
premature baby very weak food at first. It can scarcely be too 



PKEMATURE BABIES 57 

weak to start with. The food on which a premature baby 
should be started is breast milk, one-half, and a 3 percent sugar 
solution, one-half. Give a dram at a feeding every two hours 
for the first twenty-four hours of the baby's life, and start 
feeding when it is twelve hours old. The stomach of a baby 
born at term holds about one ounce, therefore the capacity of 
the stomach of a premature baby can be judged. If the baby 
is doing well, taking its food well, and if it seems hungry, the 
amount can gradually be increased. Most premature babies, 
if they are doing well, can take undiluted breast milk when from 
a week to ten days old. 

Of course a dram at a feeding of such a weak mixture as we 
have spoken of is not enough to cover the caloric needs of the 
baby; but premature babies do not have digestions which 
correspond with their theoretical caloric needs, and this is the 
difficulty. One of these babies must be fed what it can take, 
and not what it ought to have to get fat on. 

The dram feedings may be necessary only for the first few 
feedings, after which the amount may be increased. The 
amount should be increased before the strength of the food is 
increased. 

If a premature baby is born nearly at term, it is possible that 
it will be able to take the breast, but most of them are too weak 
to suckle satisfactorily; so it is usually necessary to pump the 
breast milk and to feed it with a Breck feeder or a large medi- 
cine-dropper. A Breck feeder is nothing but a big medicine- 
dropper which has a fancy name and costs a dollar and a quarter. 

The use of a medicine-dropper applies equally to premature 
babies who are fed on modified cow's milk, as well as to those 
who are taking breast milk. 

It lessens the chances of survival for a premature baby if it 
has to be fed on cow's milk, but in many cases this has to be 
done. 

The best percentage to start with is — 

Fat 1 percent Sugar 4 percent Protein 0.5 percent 

or it can be started on one-half whey and one-half 4 percent 
sugar solution, adding a small amount of 16 percent cream to 
give a little fat as the baby gets older. 



58 INFANT FEEDING (BOSTON METHODS) 

If premature babies have trouble with their digestions, — 
vomiting or loose bowels, — they should not be starved or given 
a cathartic, as they do not stand either of these procedures at 
all well. The treatment of indigestion in prematures is to cut 
down the strength or amount of the food or to lengthen the in- 
tervals of feeding. It is especially important to guard the 
premature baby against infections of any sort ; what might not 
hurt another baby, such as a slight cold in the head or a mild 
bronchitis, might prove fatal to a premature. 

Prematures need a good deal of water inside, but none outside. 
The water should be given between each feeding, the amount 
being the same amount as the feeding. 

What is the prognosis for premature babies? These three 
facts were brought out from an analysis of 125 cases by Dr. 
Maynard Ladd : The mortality was 65 percent in babies weigh- 
ing under four and one-half pounds at birth. A baby under 
this weight is very likely to die. Second, no child weighing 
less than two and one-half pounds lived. Third, no child at the 
sixth month of gestation lived. 

A premature baby needs an extreme amount of painstaking 
care. Nothing in the world is harder to take care of, both as to 
its feeding and as to its general care. 



LECTURE IV 

DIFFICULT FEEDING CASES— THE VARIOUS TYPES OF 
INDIGESTION— THE STOOLS IN INFANCY- 
CONSTIPATION 

I am going to talk today about the feeding of abnormal babies 
and the different types of indigestion and of nutritional dis- 
turbances. 

There is no absolutely satisfactory classification of digestive 
disturbances; the classification which I am going to give you 
has its faults, but it is, in the main, fairly satisfactory. The 
basis of it is this: We look upon the baby's food as being com- 
posed of elements, of which we have already spoken many times, 
and we look upon the disturbances of digestion and nutrition as 
being for the most part due to an excess or deficit in the food of one 
or more of the food elements, or faulty digestion or absorption of 
one or more of these elements, when they may perhaps be present 
in normal amounts in the food. The food as a whole, of course, 
has also to be considered, as does the proper relationship of the 
food elements to each other; that is, the baby must have a well- 
balanced food, and one element must not be present in it in great 
excess, as compared to the others. 

The classification is as follows: 

1. Too little food — starvation. 

2. Disturbances of digestion. 

a. Too much food as a whole. 

b. Fat indigestion. 

c. Sugar indigestion. 

d. Protein indigestion. 

e. Starch indigestion. 

Too Little Food, or Starvation. — First of all, let us take up 
class 1. There are a great many babies who have not had 
enough to eat, and that is the cause of their troubles. Some of 

59 



60 INFANT FEEDING (BOSTON METHODS) 

these babies, if the starvation has continued long enough, may 
present the typical picture of the so-called " marasmus" or 
"infantile atrophy." These are likely to be babies who have 
been fed on condensed milk or on one of the proprietary foods, 
or on milk diluted too much, and have been shifted about from 
one food to another — never doing well on any of them. In 
consequence, the baby is starved ; its digestion is also extremely 
weak. This is a common type of case. In such cases first 
examine the baby carefully to exclude wasting diseases, like 
tuberculosis and syphilis, in order to make sure that the baby is 
suffering from malnutrition alone. One should always be 
suspicious of tuberculosis or syphilis in small, poorly nourished 
babies. Go into the previous feeding history carefully, and 
see what the child is taking at the present time and how much 
it is getting in calories. If the calories taken are below par, 
give more to eat. That is easy to say, but hard to do, be- 
cause any baby fed for a long time on an insufficient amount 
of food has a very weak digestion, and it is necessary to 
start with a weak food and gradually increase it in dealing with 
these babies. The fat percentage especially must be raised 
slowly in feeding babies of this type, because they usually have 
very poor digestions for fat. Sometimes small doses of nux 
vomica are of value in these cases, but aside from this, drugs are 
of little aid. The stools should be examined to be sure that 
there is no indigestion of any particular food element in addi- 
tion to the starvation. I will speak of the technic later. The 
examination of the stools is not the whole story in infant feed- 
ing, by any means, but it is extremely important and desirable 
to make frequent examinations of the stools of any baby who is 
not gaining properly in order to find out how well the different 
food elements are being absorbed. This is one of the funda- 
mentals of the Boston methods of infant feeding: In order to 
feed any baby intelligently the physician must regulate the food 
supply by the waste, — that is, the unabsorbed portion of the food, — 
and the food must be of such a nature that there is not too much 
waste. Find out by careful stool examination what element or 
elements of the food the baby is not digesting or absorbing, and then 
regulate the food supply in accordance with this. 

Let us consider now the disturbances of digestion. 



DIFFICULT FEEDING CASES 61 



DISTURBANCES OF DIGESTION 

Too Much Food. — A great many babies may be getting too 
much at a feeding or may be fed too often, or the food may be 
too rich. As a consequence, the digestion is upset. This type 
of disturbance may be acute or chronic, and is manifested by 
failure to gain, fussiness, colic, vomiting, and possibly by diar- 
rhea. These cases are usually not difficult to deal with. It is 
generally wise to clean out the baby at once with castor oil or 
calomel, then starve it for twenty-four hours on weak barley 
water or water. Start in then with a weak food and gradually 
build it up to the limit of the baby's digestion, watching the 
stools carefully to see that this limit is not exceeded. 

Acute Fat Indigestion. — The symptoms of acute fat indiges- 
tion from too much fat in the food are very much the same as 
the symptoms from too much food. The vomitus may be 
creamy, and the stools are likely to show a great many small 
white fat curds, or they may rarely be oily. First examine the 
stools to be sure that it is an upset from fat, and inquire into 
the diet. If a large excess of fat is found in the stools, cut 
down the fat in the diet, or cut it out entirely for a few days, 
feeding the baby on some modification of skimmed milk without 
any fat, and increasing the fat one-half percent at a time until 
the point is reached where the baby is getting enough fat and 
not too much. 

Chronic Fat Indigestion. — Babies have more trouble from 
chronic fat indigestion than from any other form of chronic 
indigestion. It is really not fat indigestion, because the fat is 
split into glycerin and fatty acids perfectly, in most cases, but 
the soaps which are formed are not absorbed. The difficulty is 
thus in the proper absorption of the fat after it has been digested. 
Clinically, chronic fat indigestion is likely to be seen in babies 
who have been fed on high percentages of fat for a long period 
of time, or in babies who have been fed on foods containing a 
large amount of carbohydrate and very little fat — especially the 
proprietary foods. The exact etiology and the chemistry of the 
condition are rather obscure. It is known that cow's milk con- 
tains a much higher percentage of volatile fatty acids than hu- 
man milk does, and also a much higher percentage of calcium, 



62 INFANT FEEDING (BOSTON METHODS) 

which combines in the intestine with these volatile fatty acids 
to form insoluble calcium soaps which cannot be absorbed. I 
believe that many cases of fat indigestion are due to this, and 
this is why so many babies with fat indigestion will do well on 
breast milk, which may contain actually two or three times as 
much fat as the cow's milk modification which they have been 
unable to handle. 

The symptoms of fat indigestion are that a baby does not gain 
in weight, is fussy and miserable, may have rickets, may vomit 
a little, and may have diarrhea or chronic constipation or an 
alternation of the two. There may be the so-called "soap" 
stools: hard, light colored, crumbly, consisting of insoluble 
soaps. The stools may again resemble scrambled eggs, with 
many small curds, or they may occasionally look normal, but 
show a large excess of fat none the less. The way to diagnose a 
fat intolerance is to examine the stools microscopically and see 
if there is an excess of fat present. The treatment is difficult; 
these are the hardest cases that one has to deal with in infant 
feeding. Some of them may present the picture of "maras- 
mus." 

For purposes of treatment the cases of fat intolerance may be 
divided into two groups: 

1. The Type With Dry, Constipated, "Soapy" Stools. — In this 
type the stools are as above described, and are usually neutral 
or mildly acid or alkaline in reaction. The treatment is to cut 
the fat entirely out of the diet for a while, and make up for this 
by adding more sugar and protein. Care must be taken, how- 
ever, not to add enough sugar or protein to give the baby a 
sugar or protein indigestion. This type of case usually does 
well on a high sugar diet, however. After a few days of a fat- 
free diet fat can gradually be added to the diet again up to the 
limit of the baby's tolerance, watching the stools carefully for 
fat to determine what this tolerance is. Usually it is well not 
to increase the fat in the diet more than one-half percent at a 
time. Sometimes these babies have to be kept on a low fat 
percentage for a long, long time, and the condition requires ex- 
treme patience on the part of both mother and doctor. It is 
not a question of a few days or a few weeks, but a question of 
months during which the baby's diet must be regulated with the 



DIFFICULT FEEDING CASES 63 

utmost care. Sometimes it is valuable to add two or three 
teaspoonfuls of olive oil a day to the baby's diet, as some of 
these babies are able to absorb a vegetable fat when they cannot 
absorb the fat in cow's milk. The method of homogenization 
of olive oil and other vegetable fats with skimmed milk is also of 
value in treating these cases, but, of course, is not applicable 
outside of two or three large cities where the homogenized milk 
may be obtained. I believe it is a mistake to add any lime-water 
to a mixture fed to a baby with fat intolerance, as this favors the 
formation of insoluble calcium soaps. If an alkali is to be used 
in these cases, sodium citrate is the one to use. I nearly forgot 
to mention one of the most important points : It is always well 
to get a wet-nurse, if possible, for a baby with severe chronic 
indigestion, whether it be of fat or of any one of the other food 
elements. 

2. The Type With u Scrambled-egg" Stools. — In this type of 
chronic fat indigestion the stools are loose, rather frequent, and 
yellow or yellowish green in color. They contain many small 
white fat curds, smell acid, and are strongly acid in reaction. 
Microscopically they show a large excess of fat. The trouble 
in these cases is due to a combination of fat and of sugar in- 
digestion, and sometimes it is hard to tell which predominates. 
What happens chemically is this: the fats and the sugars both 
break down to form volatile fatty acids, and these are present 
in the stools, partly free and partly combined with alkali to form 
soaps. It is uncertain which of these processes is primary — 
the breaking down of the fat or of the sugar. The absorption of 
the fat is hindered in a number of ways in these cases. 

Insoluble soaps are formed from the volatile fatty acids and 
calcium present in the milk to start with, and also from the 
higher volatile fatty acids which have been formed in the in- 
testine. 

The reaction of the intestine is very strongly acid, due to the 
various acids present from abnormal fat and sugar decom- 
position. Bile is a very unstable substance, especially in an acid 
medium. It may be possible that the bile is decomposed in the 
strongly acid intestine, and is thus rendered useless in the emul- 
sification of the fats which is necessary for their proper absorp- 
tion. 



64 INFANT FEEDING (BOSTON METHODS) 

It is a chemical fact that it is impossible for a good emulsion 
to be formed in a strongly acid medium. It is possible then that 
the proper emulsification of the fats is hindered in this way also. 

This condition has always been an extremely interesting one 
to me, and I must confess that in very many cases it is extremely 
difficult and sometimes impossible to tell just how much of the 
trouble is due to fat and how much to sugar. I call the condi- 
tion a fat indigestion, however, because the most striking thing 
about it is the poor fat absorption. The treatment must be 
somewhat different from that of the other type of fat tolerance, 
because here there is, in addition to the low fat tolerance, a low 
sugar tolerance. We must, therefore, feed a food low in fat and 
sugar, and high in protein. In the severe cases it is well to cut 
the fat entirely from the diet; in the milder cases it can be 
halved. The sugar should be considerably reduced, usually to 
3 or 4 percent for a while, and then increased again up to the 
limit of tolerance as the baby improves. The protein should be 
as high as the baby will stand. Usually 3 percent of protein 
will be handled fairly well by most babies over two or three 
months old when they have this type of indigestion. There are 
two reasons for feeding a high protein percentage : first, because 
the digestion for protein is usually good; second, because the 
digestion for fat and sugar will be improved if the reaction of 
the intestinal contents can be made less acid, which is what 
happens when a high protein milk is fed. 

The protein must be given in such a form that it can be easily 
handled. If an ordinary milk mixture is used, it is well to add 
two grains of sodium citrate for each ounce of milk to prevent 
the formation of tough casein curds in the stomach. 

" Eiweiss " milk is valuable in treating some of these cases, and 
if this is used, the protein is, of course, in a finely divided pre- 
cipitated form which is easily digested. 

I have never been satisfied with the treatment of fat intoler- 
ance: we really know so little about its exact chemistry and 
etiology. There are so many obscure factors that enter into it, 
concerning which the state of our knowledge is at present so im- 
perfect, that our results are by no means as good as they might be. 

Acute Sugar Indigestion. — Most babies will get into trouble 
if they are taking over 7 percent of sugar in the diet. The 



DIFFICULT FEEDING CASES 65 

symptoms of sugar indigestion are vomiting of rather thin, sour 
material, a good deal of colic and gas, and the passage of fre- 
quent, loose, green, acid-smelling movements. These move- 
ments, and the whole disturbance, are due to fermentation of 
sugar in the intestine, with the consequent formation of volatile 
acids, such as acetic and butyric, irritating the intestine and thus 
causing increased peristalsis. Sugar indigestion is likely to be 
more severe than any of the other forms of acute indigestion. 
Most of the cases will do fairly well with proper treatment, 
which is to starve the baby for twenty-four hours, starting the 
subsequent feeding with a food very low in sugar. No castor 
oil is necessary, for the baby has cleaned itself out by the diar- 
rhea it is having. After the starvation, go back to a diet with as 
little sugar in it as possible. "Eiweiss" milk fulfils these in- 
dications. It is always best to keep the sugar percentage low 
for a few days, and then very gradually add the sugar again, 
The sugar which is usually best to use in a case of this type is a 
malt -sugar preparation, because the malt-sugars have less ten- 
dency to ferment than lactose or sucrose, and are absorbed more 
quickly. 

There are no hard-and-fast lines to be drawn between sugar 
indigestion and what I call fermentative diarrhea, because in 
most cases of sugar indigestion there is likely to be a good deal 
of fermentation. We shall discuss this fermentative diarrhea 
at the next lecture. 

Chronic Sugar Indigestion. — Chronic sugar indigestion is not 
so common as chronic fat indigestion. The symptoms are very 
much the same as in acute sugar indigestion: the passage of 
loose, watery, green, acid-smelling stools. The baby's buttocks 
are likely to be red and irritated from the acids in these stools. 
When stools of this type are present, it is certain that there is 
fermentation of sugar in the intestine, and the indications are 
to feed a low sugar percentage. These cases are not so chronic 
as the fat cases. Generally, after giving a low sugar percentage 
for a few weeks, in combination with a high protein, the sugar 
tolerance will be so increased that a reasonable sugar percentage 
can be given again. 

Acute Protein Indigestion. — Acute indigestion from protein is 
common. It shows itself by the vomiting of large, tough curds, 
5 



66 INFANT FEEDING (BOSTON METHODS) 

due to coagulation of the casein in the stomach. Besides this, 
there is likely to be a good deal of colic and abdominal pain, 
with or without diarrhea. There are very likely to be hard, 
large curds of casein in the stools. The stools may be of two 
sorts — yellowish or brownish, with these large curds; or of a 
brown color, loose, with a strongly musty, foul smell, with no 
curds. The treatment of protein indigestion is to cut down the 
protein in the milk. Usually in the type where the stools are 
yellow, with the curds present, this is sufficient to cure the 
trouble — to starve the baby for twenty-four hours and cut down 
the protein in the subsequent diet. In the other type the con- 
dition is a good deal more serious, and it is usually best to starve 
the baby a little longer, giving it a lactose solution of 6 or 7 
percent with starch to 0.75 or 1 percent. In the subsequent 
feeding the sugar in the diet should be kept relatively consider- 
ably higher than the protein, as there is alkaline decomposition 
going on in the intestine and it is desirable to change the reaction 
of the intestine from alkaline to acid. This is usually the worst 
type. If tough curds are being vomited or passed in the stools, 
some of the methods which I have mentioned before of making 
the protein easily digested in the stomach may be used. This 
condition of protein indigestion usually clears up very well. 
Most babies will get over it in a few days with the proper treat- 
ment. 

Chronic Protein Indigestion.— Chronic protein indigestion is 
not very common, and when it is seen, it is usually accompanied 
by the loose, brown, musty-smelling stools. The treatment is 
to feed a food low in protein and high in carbohydrate. 

Starch Indigestion. — I am not going to speak of acute starch 
indigestion because it is rare, and chronic starch indigestion is 
the more important. Chronic starch indigestion is often seen, 
especially in older children. In small babies it may occur when 
over 1 to 1.5 percent of starch is being fed in the diet. The 
symptoms are very much the same as those of fat indigestion. 
The stools are different; they may be brown and gelatinous, 
with many small, jelly-like particles scattered through them, 
or they may more rarely be loose and green, like the stools of 
sugar indigestion. The treatment, of course, is to cut out the 
starch and make up the deficiency with the other food elements. 



DIFFICULT FEEDING CASES 67 

Of course, this classification we have been discussing is not 
at all hard and fast, because when one type of indigestion is 
present, there may be also present some other type. Generally 
one type predominates, however, but the digestion may be also 
weakened for some of the other food elements. 

You will notice that in discussing these nutritional disturb- 
ances I have not mentioned the salts. These are, of course, of 
very great importance, but we know so little about the metab- 
olism of the salts, and the whole question of their role in nutri- 
tion is so complicated, that, with the present state of our knowl- 
edge, we can take them into very little consideration in practical 
feeding. 

Now I want to talk about chronic fat and starch indigestion 
in older children. This is a common condition. I have seen a 
number of cases of this type since I have been here. The usual 
story is that there has been a good deal of trouble with the child's 
digestion from the first, and the trouble does not seem to im- 
prove much as the child grows older. These children may be 
anywhere from two to eight or ten years of age, and I have seen 
a typical case of "marasmus" from chronic starch indigestion 
in a child of twelve. These children are much under weight, 
and sometimes may be so much emaciated that they are little 
more than skin and bones. They are underdeveloped in every 
way, fretful and irritable, and, on the whole, pretty miserable- 
looking specimens. 

The abdomen is usually considerably distended, and the chest 
apparently very small in relation to the abdomen. Rickets 
may or may not be present, and there is usually considerable 
anemia. There is no use experimenting with different foods in 
these cases until the cause of the child's indigestion has been dis- 
covered. It is impossible to feed these children intelligently until 
the stools have been examined to see what the child is digesting and 
what it is not digesting, and by this make a diagnosis of the type of 
indigestion and regulate the food supply accordingly. 

Fat Intolerance. — In feeding these cases the utmost care is 
necessary, and it is usually very hard to manage them when the 
children stay at home, because the parents are likely to give 
them anything they want to eat. Generally the digestion for 
every food element is weak, but especially so for fat. For these 



68 INFANT FEEDING (BOSTON METHODS) 

cases write out an absolutely iron-clad diet list, showing just 
what the child is to eat in the twenty-four hours. Most cases of 
this sort must be on a carefully regulated diet for a year or 
two years before the digestion returns to anything like the 
normal. Sometimes if a child gets to the table and eats a piece 
of butter the size of a pea it will be completely upset again. 
It is necessary to keep the child on a fat-free or a very low fat 
diet, the diet being made up mostly of starchy and protein foods. 
As to drugs, it is usually of a good deal of advantage to get these 
children cleaned out with castor oil once a week, as the intes- 
tines may be sluggish. Nux vomica is also a very good drug 
to give. For anemia, of course, iron is indicated. Needless to 
say, have the child get all the fresh air possible and live in a sen- 
sible and hygienic manner. Excellent results can be obtained 
with these cases if the family is intelligent and will carry out di- 
rections; but if one is dealing with an ignorant and stupid 
mother who will not carry out all directions absolutely, it is 
hopeless to expect to get good results. 

You can, perhaps, get a better idea of cases of this sort by a 
discussion of a concrete case. This history is of a girl of five 
years who entered the Children's Hospital April 14, 1916. It 
is a very typical case of fat intolerance. 

History 

Past History. — Normal delivery. Breast fed for five months. 
Birth weight, six pounds. After five months breast milk gave 
out and the child was put on Eskay's Food for a month. After 
this she was fed on barley gruel and whole milk. She did fairly 
well up to a year ago. 

Present Illness. — About a year ago she began to have diar- 
rhea. This diarrhea would last for about a week, then she 
would apparently be perfectly well for a while, when the diar- 
rhea would return. During the periods of diarrhea she would 
have six to eight loose, light-colored stools in twenty-four hours, 
without mucus or blood. Most of the time she has been kept 
on a fairly careful diet, except that she gets off with the other 
children occasionally and eats a good deal of candy, etc. At 
these times her digestion appears to be especially upset, and she 
vomits and the diarrhea becomes more marked. No vomiting 



DIFFICULT FEEDING CASES 69 

at any other time. For the last week she has been so weak she 
has had to stay in bed, and has been on a diet of bread and milk, 
beef -juice, port wine, and albumin water. 

Weight one year ago, 31 pounds; now, 183/2 pounds. 

Short Summary of Physical Examination. — Very poorly de- 
veloped and nourished. Pale. Skin dry and loose. Glands, 
moderate general enlargement. Abdomen very large, tym- 
panitic save in flanks, where there is shifting dulness. No fluid 
wave. No masses, spasm, or tenderness. 

Stool brown, hard, smooth, alkaline; no mucus. Microscopi- 
cally shows a large excess of neutral fat and soaps. No starch. 

This girl was treated as follows : She was at first kept in bed, 
as she was too weak to stand. These drugs were given: 

Tincture nux vomica 5 minims three times daily 

Saccharated oxid of iron ... 5 grains " " " 

Castor oil was needed about once a week, as she had a good 
deal of distention at times, and a thorough cleaning out oc- 
casionally seemed to help her a good deal. 

The diet was scanty at first, but was gradually increased as 
she grew stronger. 

April 15th she took: 

Zwieback 3 slices 

Beef -juice 2 ounces 

Cereal (farina) 3 tablespoons 

Fat-free milk 24 ounces 

She improved rapidly, and was soon strong enough to be up 
and around the ward. The stools varied a good deal. Some- 
times they were hard and constipated, sometimes they looked 
normal, and sometimes they were very loose and foul. The fat 
was never in excess while she was on the low fat diet. 

May 9th she was taking: 

Cereal (farina) 1 tablespoon 

Bread (stale) 2 slices 

Zwieback 3 " 

Beef-juice 3 ounces 

Chopped meat 1 ounce 

One egg 

Juice of half an orange 

Apple-sauce 2 tablespoons 

Fat-free milk 24 ounces 



70 INFANT FEEDING (BOSTON METHODS) 

She was kept on practically this same diet until she was dis-* 
charged, very greatly improved. 

Her weight at entrance was 18 pounds 4 ounces. 

Her weight at discharge was 24 pounds 8 ounces. 

Average gain per week, 9 ounces. 

I have not happened to see this particular girl since she left 
the hospital, but it is certain that if her mother has not dieted 
her strictly she is in just as bad condition as she was before she 
entered the hospital. If her mother takes pains to diet her 
carefully, she will probably get along very well. 

Starch Intolerance. — The symptoms of starch indigestion are 
very much the same as those of fat indigestion. The stools are 
different, being brown and loose, with a great deal of jelly-like 
material. There is also likely to be a great deal of cellulose in 
the stools. Sometimes the stools of cases of starch indigestion 
may be green and watery, and sometimes may be extremely 
foul. If the diet of these children is investigated, it will be found 
that they eat a tremendous amount of starch in the form of hot 
bread, potatoes, etc., and also a good many green vegetables 
and fruits. The thing to do in these cases is to cut out the 
starch as much as possible. Of course it cannot be cut out en- 
tirely, because children of this age depend so much upon cereals. 
However, it can be cut down considerably, and coarse vege- 
tables and fruits can be removed from the diet. The starch that 
is taken should be very thoroughly cooked. Any cereals these 
children take should be cooked overnight. The diet list should 
be written down. It can be practically the same from day to 
day, for most children do not at all mind a monotonous diet. 
The essential things are to feed a low starch, thoroughly cooked 
diet, cut out the fruit and coarse vegetables, and have all the 
food the child takes in as finely divided a form as possible. 



THE STOOLS IN INFANCY 

There are a few points I want to mention about the stools in 
infancy. If any of you are interested, you will find the subject 
discussed more fully in Dr. Morse's "Case Histories in Pedi- 
atrics," which I have recommended to you before. 

The examination of the stools is of very great importance, 



THE STOOLS IN INFANCY 71 

both macroscopic and microscopic, and usually altogether too 
little attention is paid to it. It is perfectly obvious to any one 
that it is a rational and sensible thing, when dealing with a baby 
who has indigestion, to examine its stools carefully and get as 
much information as possible from this source. However, stool 
examination is not the whole story in infant feeding by any 
means, and the weight and general condition of the baby must 
also be considered. Stool examination is perhaps the most im- 
portant guide we have, however, and if one is expert at it, a 
great deal may be learned about what is going on in the baby'3 
intestine, by a careful examination of the discharges. 

The reaction of the stools is sometimes of considerable im- 
portance. In the infant's intestine two processes are continu- 
ally working against and counterbalancing each other: decom- 
position of fat and carbohydrates, with acid end-products, and 
decomposition of protein, with alkaline end-products. These 
two processes, under normal conditions, just about balance 
each other, so that a normal stool is either slightly alkaline, 
neutral, or slightly acid in its reaction. If the intestinal con- 
tents are too strongly acid or too strongly alkaline, trouble 
usually results, due to the irritant action in the intestine of the 
acid or alkaline end-products. 

Some of the various types of abnormal stools seen are as 
follows : 

1. Fat Indigestion. — The stools in this condition may be of 
a number of types: 

(1) The " scrambled-egg " stool, acid smelling, loose, and with 
many soft, white fat curds scattered through it. With stools 
of this type there is also probably some sugar indigestion in 
addition to the fat. 

(2) The "soap stool," usually a hard, light-colored, rather 
dry and crumbly stool, sometimes almost white. Typical soap 
stools are made up very largely of insoluble calcium and mag- 
nesium soaps. 

(3) The oily stool. Sometimes in cases of fat indigestion the 
stool may be a light yellowish-brown color and very oily. These 
stools are not particularly common. 

(4) Some stools which contain a large excess of fat may look 
perfectly normal macroscopically, but when examined under 



72 INFANT FEEDING (BOSTON METHODS) 

the microscope will be seen to contain a large excess of fat. 
These stools are usually of a salve-like consistence. 

2. Sugar Indigestion. — The stools of sugar indigestion are 
always strongly acid in reaction. They are usually loose, 
green, strongly acid smelling, and may contain fat curds, due 
to the fact that the stool has been hurried through the intestine 
so fast that the fat has not had time to be absorbed. The stools 
of mild sugar indigestion may sometimes closely resemble the 
" scrambled-egg " stools of fat indigestion previously described. 

3. Protein Indigestion. — The stools of protein indigestion 
may be of two types. The first type is usually yellowish or 
light brown, and contains casein curds, which are smooth, tough, 
white, bean-shaped masses of coagulated casein. The second 
type is brown, loose, foul, strongly alkaline in reaction, and may 
be frothy or bubbly. This type of stool indicates that there is 
considerable decomposition of protein going on in the intestine. 

4. Starch Indigestion.— The stools of starch indigestion are 
usually loose, foul smelling, rarely smooth or homogeneous, are 
brown in color, and are likely to contain small, brown, mucilagin- 
ous masses of partly digested starch, together with a good many 
coarse cellulose remains, such as seeds, pulp of fruit, etc. Oc- 
casionally the stools from cases of starch indigestion may be 
dry and orumbly or more rarely green and watery. 

By all means the most common type is the one first described. 

Microscopic Examination of the Stools. — The microscopic 
examination of the stools is important. By microchemical 
methods we test for fat or starch. 

The technic of the fat test is as follows : 

Place a small portion of the stool on a glass slide, add a drop 
or two of glacial acetic acid and a drop or two of a saturated 
alcoholic solution of Sudan III stain. Rub up the stool, acid, 
and stain together, and heat gently for a moment over an al- 
cohol lamp. Examine with the low power of the microscope; 
the fat shows itself as small, orange-red globules. Nearly all 
stools contain a fair amount of fat, and whether or not the fat 
is in excess in any given stool preparation can be told only by a 
certain amount of experience with the method. If a baby is 
doing well in every way, it is not necessary to change the food 
if there is a slight excess of fat in the stool. 



CONSTIPATION 73 

This method, used in this way, gives the total fat in the stool 
and does not differentiate between neutral fat, fatty acids, and 
soaps. What one wants to know in most stools is the total fat 
content, so I will not go into the technic for the differentiation 
of soap, etc. 

The test for starch is simpler : 

Add a drop or two of official tincture of iodin diluted 1 : 15 
with 95 percent alcohol to a small portion of the stool, and ex- 
amine under the microscope. Starch-granules stain dark blue. 
It is abnormal for there to be any but the very smallest amount 
of starch in a stool. 

CONSTIPATION 

I will finish the lecture by talking very briefly about consti- 
pation. Constipation in small babies and in children during 
the second year is an extremely common condition and one hard 
to deal with. There may be a number of causes. The first is 
mechanical. The large intestine is relatively a good deal longer 
in a child than in an adult. The sigmoid flexure is longer and 
the mesentery is longer. There are thus a good many chances 
for kinks in the intestine, which may partially obstruct the 
passage of stools. It is well to bear in mind that this is cer- 
tainly sometimes the cause in some of the severe cases. 

There are a great many other causes, too, but we need not go 
through all, and will take up only the two most important. 
The first is atony of the abdominal muscles and intestine; the 
second is the character of the food. 

In a great many babies constipation may be caused by the 
flaccid condition of the intestines and abdominal muscles. 
The child has not enough strength in its abdominal muscles to 
strain down and force out the feces. The abdomen is very 
flabby. Of course, the treatment of such a case as this is to 
increase the general strength and well-being of the child, if 
possible. Nux vomica is usually a good drug to use. In an 
older child exercise of the abdominal muscles is valuable. Of 
course, if there is anemia or any diseased condition, iron is 
indicated for the anemia and suitable drugs for the other con- 
ditions. 

Constipation may be caused by either too little or too much 



74 INFANT FEEDING (BOSTON METHODS) 

fat in the food. If the food is very low in fat, there is likely to 
be so much of the food absorbed that not enough is left in the 
intestine to cause a good movement of the bowels. If there is 
too much fat in the food, constipation may sometimes be caused 
by the formation of hard, dry "soap stools." 

These are the most usual causes of constipation. 

If a baby who is supposed to be constipated has a stool the 
moment his anus is irritated with a suppository or a piece of 
oiled paper, he has not constipation at all, but does not defecate 
simply because he is lazy and does not care particularly whether 
he empties his bowels or not. All that is needed in such a case 
as this is training. 

What is to be done for a case of constipation? First, let me 
say that in a good many cases, no matter what is done, the 
results are poor. 

Diet. — The diet is of great importance. If the child is fed on 
cereal waters, oatmeal is the best one to use, as it is somewhat 
irritating to the intestine and will help to cause peristalsis. If 
the child is not getting enough fat, give more; if it is getting too 
much, cut it down. Properly prepared green vegetables are of 
value, chopped-up spinach, celery, or carrots being very good. 
Orange-juice or prune- juice or finely scraped apple will some- 
times help. 

The malt-sugar preparations, such as maltine malt soup, are 
often of great value, as maltose is very laxative, and sometimes 
obstinate constipation in a small baby can be corrected by sub- 
stituting malt for milk-sugar without any other measures. 
Dextri-maltose, however, is constipating, owing to its high con- 
tent of dextrins. 

Drugs. — In the atonic cases tincture of nux vomica is some- 
times of great value, and may do more good than either diet or 
cathartics. 

Iron is indicated if the child is anemic. " Eisenzucker " 
(saccharated oxid of iron) is the best preparation to use, as some 
of the other iron preparations have a tendency to cause consti- 
pation. 

Laxatives. — Use laxatives as little as possible in the treatment 
of constipation; they may relieve the condition for a while, 
but do not get at the cause of it. 



CONSTIPATION 75 

Such cathartics as castor oil and calomel should not be used; 
they are too irritating for continued use. 

The best laxative for small babies is milk of magnesia, and for 
older babies and children, phenolphthalein, in doses of from 1 to 
3 grains. 

Agar-agar, which is a preparation of finely ground seaweed, 
may be of value. It is given in doses of a teaspoonful two or 
three times a day, mixed up with the child's cereal or potato. 
Of course, it cannot be used for babies who take only milk. It 
is not absorbed, but increases the bulk of the stool by swelling, 
which tends to cause a good movement. 

The various mineral oils which are on the market are also of a 
certain amount of value. 

Suppositories are bad for continued use as they establish a 
bad habit for the baby and make it think that it cannot have a 
movement of its bowels unless previously stimulated with a 
suppository. If enemas have to be used, plain soap and water 
ones are the best. 

Constipation is a very fussy condition to treat, and requires a 
good deal of care. I have merely attempted to give a very brief 
summary of some of its most important aspects. 



LECTURE V 
DIARRHEAS OF INFANCY 

1. Nervous. 

2. Mechanical. 

3. Fermentative. 

(a) Carbohydrate form. 

(b) Protein form. 

4. Infectious: 

(a) J D y senter y- 

^ ' \ Streptococcus. 
(b) Gas bacillus. 

I am going to talk today about the diarrheas of infancy. 
There is a great deal of difference of opinion among various 
pediatric teachers and schools about the etiology and treatment 
of these diarrheas, so I have no right to speak dogmatically in 
discussing such a question, but am going to do so for the sake of 
clearness. 

What is diarrhea? What causes diarrhea of any sort? 
Diarrhea is caused by increased intestinal peristalsis. That is 
at the bottom of every diarrhea, whether it be of a baby or of an 
adult. Increased peristalsis may be brought about by a num- 
ber of causes, as follows: 

1. Reflex nervous influences. 

2. Irritation of the intestine mechanically by seeds, skins of 
fruit, improperly chewed food, etc. 

3. Irritation of the intestine by injurious chemical products 
of food decomposition. 

4. Bacterial infection of the intestinal mucous membrane. 
What sorts of diarrhea are seen in infancy? Of course, all 

diarrheas are not the same, and it is not enough to say, in the 
case of any baby who has diarrhea, that it has " ileocolitis " or 
"summer complaint." It is necessary to diagnose the diarrhea 
more accurately and determine what type of diarrhea it is, and 

76 



DIAKRHEAS OF INFANCY 77 

to what it is due before it can be intelligently treated, for 
different sorts of diarrhea require different treatment. 

NERVOUS DIARRHEA 

First of all, there is a nervous diarrhea. Such a diarrhea as 
this may be caused by infection or disturbance of one sort or 
another outside of the digestive tract, reflexly causing increased 
intestinal peristalsis, and thus a diarrhea. There is no question 
of any bacterial infection of the intestine in such a diarrhea as 
this. This type of diarrhea may be seen with otitis media, or 
with any acute infection which disturbs the equilibrium of the 
child. Again, nervous diarrhea may be caused by heat, by 
prostration, by teething, or by undue excitement. Nervous 
diarrhea is usually controlled by reducing the food. It is often 
best, in very hot weather, to weaken the food, and also during 
severe teething, or in acute infections, such as pneumonia, 
measles, etc. 

MECHANICAL DIARRHEA 

Mechanical diarrhea is caused by irritation of the intestine by 
such things as seeds, skins of fruit, and various sorts of indiges- 
tible material. The child's intestine is much more susceptible to 
irritation of this sort than is that of the adult, and this is why it 
is wrong to feed raw fruit or coarse green vegetables to small 
children. There is nothing particularly to be said about this 
type of diarrhea. The stools always contain portions of un- 
digested material, so the cause of the diarrhea is readily ascer- 
tained. A diarrhea of this type is likely to be accompanied by 
more gastric disturbance than are most of the other diarrheas of 
infancy and childhood. The treatment is thoroughly to empty 
the intestines with calomel or castor oil, to withhold food for 
twenty-four hours, and then to start in with a weak, easily 
digested food, keeping the child on a rather scanty diet for a few 
days, after which the regular diet may be resumed. 

FERMENTATIVE DIARRHEA 

Fermentative diarrhea, the third type, is an extremely com- 
mon condition. In Boston we see more cases of this type than 
of any other. Probably many of your cases, too, are of the fer- 



78 INFANT FEEDING (BOSTON METHODS) 

mentative type. This is a diarrhea caused by the abnormal 
decomposition of food material in the intestine, giving rise to 
products which irritate the intestinal mucous membrane and 
cause diarrhea. The mucous membrane is not attacked by bac- 
teria in this condition. It is simply the food in the intestine 
that is attacked and decomposed, and the resulting products 
irritate the intestine and stimulate it to increased peristalsis. 
Diarrhea of this type may be of two sorts — the carbohydrate 
form, in which the carbohydrates in the intestine are the sub- 
stances that are being decomposed, with the formation of acid 
end-products; and the protein form, in which the protein sub- 
stances are being decomposed, with alkaline end-products. 

By all odds the most common type is the carbohydrate form, 
and this is the usual "summer diarrhea" that is seen in infants. 
It occurs especially in the summer, and is rarely seen in the cool 
months. The etiology may be due to many factors and con- 
ditions. It is unquestionably due partly to heat; but the exact 
way in which heat influences the baby is not well understood. 
It may be caused by feeding too much sugar to the baby, either 
as too high a sugar percentage, or as too much food at a feeding. 
The sugar is not absorbed, and what is left behind ferments. 
It may be caused by dirty milk, which carries into the intestine 
all sorts of harmful organisms: the Bacillus proteus, the gas 
bacillus, the colon bacillus, etc. There has been much dis- 
cussion about the exact organism which causes fermentative 
diarrhea, but the question of the bacteriology of the intestine is 
so complicated that it is impossible to lay the blame at the door 
of any one organism. We know that usually it is caused by 
organisms of a number of different sorts which enter the body in 
contaminated milk, but we also know that it may be caused by 
the normal flora of the intestine, under certain conditions. 
Summer is, of course, the most favorable time for milk to be- 
come infected. If the milk is pasteurized or sterilized, or if it is 
certified milk, it is very unlikely to produce fermentative diar- 
rhea, and the condition is not nearly so common among the 
better classes, who take good care of their milk, as it is among 
the poorer classes, who do not. 

The prominent symptom of fermentative diarrhea due to 
carbohydrate decomposition is the passage of loose, green, acid 



DIARRHEAS OF INFANCY 79 

stools containing mucus. The stools are always strongly acid and 
smell acid. They are usually green. The number may vary a 
good deal — there may be three or four or five in a day, or 
twenty or twenty-five. The severity of the attack may vary 
a great deal. The child may appear not to be sick at all, but 
may have these stools ; or there may be a great deal of toxemia, 
with high temperature, and the child may die. The tempera- 
ture may be normal or may be very high. There is not a great 
deal of vomiting, because the condition is primarily an intes- 
tinal one, and the stomach has very little to do with it. The 
buttocks are likely to be red and irritated from the strongly 
acid stools. The abdomen in the severe cases may be sunken, 
also the eyes, and the fontanel. Nervous symptoms are not so 
common as in true " infectious diarrhea." You have all seen 
so many of these cases that it is not necessary to discuss the 
symptoms further. 

The sugar in the intestine is attacked by bacteria and broken 
down. Formic, acetic, and butyric, as well as many other 
acids are formed from the breaking down of the sugar. A 
certain amount of formaldehyd is also likely to be produced. 
It is surprising to see how much strong acetic and butyric acid 
may be recovered from the stools of babies with this condition, 
and when one realizes how much concentrated acid is present, 
it is easy to understand how tremendously the intestine is irri- 
tated by it. 

Of course, in this condition the absorption of all the food 
elements is lessened, partly on account of the increased peris- 
talsis and partly on account of the abnormal acidity of the 
intestine. 

There is likely to be an acidosis present in a good many of the 
cases, partly due to the greatly increased loss of alkali in the 
diarrheal stools and partly due to the usually diminished ex- 
cretion of the kidneys and the abnormal breaking down of body 
fat if the baby is not taking much milk. 

The prognosis varies a great deal. It is usually very good in 
the mild cases in large, strong babies. It is doubtful or bad in 
the more severe cases in small, poorly nourished babies. Often 
a small baby will die in twenty-four hours from fermentative 
diarrhea. 



80 INFANT FEEDING (BOSTON METHODS) 

Treatment. — You may be sure in any diarrhea that if the 
stools are green, acid smelling, and strongly acid in reaction the 
condition is due to sugar fermentation. What are the indica- 
tions for treatment? As the condition is due to a sugar fer- 
mentation, it is reasonable to give a milk as low in its sugar con- 
tent as possible, to arrest this fermentation. If, in the food, a high 
protein content can be combined with this low sugar content, a good 
deal will have been gained, for the disintegration products of protein 
are alkaline in reaction .and will help to neutralize the acid condi- 
tion in the intestine, restoring it to its normal balance. The with- 
drawal of sugar and the substitution of protein will also tend to 
inhibit the growth of the bacteria which have been causing the 
condition. 

These are the principles of treatment. 

Details of Treatment. — In severe acute cases it is usually 
better to starve the child for twenty-four hours, giving it merely 
water. In the milder cases starvation is not at all necessary. 
As to purgatives, personally I do not at all believe in giving 
them to cases of fermentative diarrhea due to carbohydrate, 
when the child is having 10 to 15 or 20 stools a day; as it is 
cleaning itself out, and it is not necessary to have any further 
cleaning. The intestine is already very much irritated, and it 
is poor therapeutics to irritate it any more. But if the baby is 
having only three or four bad-looking stools, by all means give 
a purge of castor oil or calomel to clean out the intestine. After 
the starvation period of twenty-four hours, feeding can be 
started. There are two or three different methods which can be 
used, but the principle is the same in all. 

1. Start on skimmed milk and water dilutions, giving the 
baby such a formula as this: Skimmed milk, one-half; water, 
one-half. The percentage is this: Fat, 0; sugar, 2.25; protein, 
1.6. Of course, no definite rules can be laid down for increasing 
the strength of the milk, as this will depend upon the clinical 
condition. Keep the fat low for a considerable length of time, 
also the sugar, and go up on the protein. When sugar is added, 
use a malt-sugar preparation instead of milk-sugar. Keep the 
sugar very low until the stools have become solid. 

2. Another way of feeding these cases is by the use of "Ei- 
weiss" milk, of which I have already spoken in the last lecture. 



DIARRHEAS OF INFANCY 81 

This is extremely satisfactory in such cases and they will get 
well much more quickly than with simply skimmed milk and 
water. The disadvantage is that Eiweiss milk is hard to make, 
but if one is dealing with an intelligent family, they can make 
this milk, and it is by all odds the best thing to feed these cases 
on, because one can get in it a much higher protein percentage 
and a lower sugar percentage than by any other means. Ei- 
weiss milk has this composition, you remember: Fat, 2.5; 
sugar, 1.5; protein, 3.5; or if skimmed milk is used instead of 
whole milk, the fat is reduced nearly to zero. 

3. There is another method: the use of skimmed milk and 
water mixtures to which powdered casein has been added. The 
great trouble about this is that it is hard to get powdered casein. 
There was a good product on the market some time ago called 
"Larosan," but I am not sure whether this can be obtained now. 
Buttermilk is also sometimes of value in feeding these cases, as 
it combines a high protein with a fairly low sugar content. So 
much for the feeding. 

Drugs. — I do not wish to give the impression that drugs are 
of no value in treating this condition, but I distinctly do wish to 
give the impression that the regulation of the diet is by far the 
most important part of the treatment. It is very rarely neces- 
sary to give a drug of any sort to a baby with fermentative 
diarrhea. 

Purgatives. — As I said before, purge the baby with castor oil 
or calomel if it has not already cleaned itself out well; if it is 
having numerous stools already, give no purgative. It is a 
great mistake to give repeated daily doses of calomel or castor oil 
to a baby who is already exhausted by diarrhea. 

Bismuth. — Bismuth does very little good in fermentative 
diarrhea, and it obscures the stool picture, so one cannot tell 
the nature of the stool, and thus cannot regulate the diet in- 
telligently. Proper food regulation will usually stop the diar- 
rhea without using bismuth. 

Opium. — Theoretically, opium is contraindicated because it 
is unwise to tie up the intestine and thus favor absorption of 
toxic material. Practically, when a baby is having many 
watery stools a day, with a good deal of straining and tenesmus, 

6 



82 INFANT FEEDING (BOSTON METHODS) 

with perhaps a prolapsed rectum, it is wise to give opium in 
some form, usually paregoric, to relieve it. 

Intestinal Antiseptics. — The intestinal antiseptics are of very 
little value in treating fermentative diarrhea : if you give enough 
to sterilize the intestine, you give enough to kill the baby. 
Bulgar tablets, which are so commonly used, are very likely to 
be inactive, and I am very skeptical about their value, even if 
they are active. 

Colonic Irrigations. — The trouble in fermentative diarrhea is 
usually so high up in the intestine that little benefit is to be 
obtained from colonic irrigation. 

Fluid. — It is extremely important to give the baby plenty of 
fluid, either by mouth, rectum, or by subcutaneous injection, 
if necessary. Next to the feeding, this is the most important 
part of the treatment. 

Alkalis. — Theoretically, it would seem that as the trouble in 
fermentative diarrhea due to carbohydrate fermentation is 
caused by the excessive production of acid in the intestine, al- 
kalis would be indicated. Practically, it is much easier to 
change the reaction of the intestine by the use of suitable food 
than by alkalis. In certain cases of fermentative diarrhea 
there may be a good deal of acidosis, however, which may be 
manifested by rapid and labored breathing, by stupor, or by 
extreme restlessness. If acidosis is suspected, an alkali is in- 
dicated. Sodium bicarbonate may be used, either by mouth or 
by rectum, usually best by rectum, as it has a good deal of 
tendency to upset the stomachs of small babies. 

You will see that I am somewhat of a drug nihilist as regards 
this condition; to my own cases I rarely give a drug, with the 
exception of an occasional dose of opium or castor oil. I 
understand perfectly that a doctor has to give drugs to many 
people if he wants to keep them as patients, and do not believe 
that such drugs as bismuth, salol, etc., do any harm. 

In fermentative diarrhea due to protein the general symptoms 
are very much the same as in the carbohydrate form, which we 
have been discussing, except for the stools. The stools in pro- 
tein fermentative diarrhea are loose, watery, brown, and rather 
musty or foul smelling, and they are alkaline in reaction. The 
condition is due to decomposition of protein in the intestine; 



DIARRHEAS OF INFANCY 83 

therefore it is treated by giving a milk low in protein and high 
in carbohydrate. The first food which it is usually best to 
give is a 5 to 7 percent solution of milk-sugar, to which barley 
water may or may not be added, keeping the protein low for a 
while, and gradually increasing the strength of the food by add- 
ing skimmed milk or whole milk, and more sugar. These cases 
will usually do well with proper treatment, but some of them 
may be troublesome. The general treatment is the same as 
for the carbohydrate form. A hundred carbohydrate cases 
are seen to one of the protein type. 



INFECTIOUS DIARRHEA 

Infectious diarrhea is the type of diarrhea that most of you 
see down here. It is called by different names: ileocolitis, 
dysentery, etc. This condition may be due to a number of 
organisms, which may be divided into two groups, — the dysen- 
tery bacillus and the streptococcus, — which I put together be- 
cause the treatment for them both is the same; and the gas 
bacillus group, for which the treatment is different. As you 
will note, this classification is based on the treatment. The 
etiology is infected milk in nearly all cases, and if the disease is 
seen in breast-fed babies, it means they have been having some 
food in addition to the breast milk, or may possibly have re- 
ceived the infection through water. 

In infectious diarrhea there is an actual invasion of the intes- 
tinal mucous membrane by bacteria; thus it is a different thing 
entirely from fermentative diarrhea. 

First of all I want to speak of the gas oacillus type. There 
has been a great deal of discussion, especially in Boston, as to 
just what role the gas bacillus plays in infectious diarrhea. 
We find it in a certain number of cases, and we know that when 
we get rid of it the cases improve a great deal. From that line 
of reasoning we consider that in these cases the gas bacillus is 
the cause of the disease. Some men say that it has nothing at 
all to do with it, and that it is simply present in the intestine, 
doing little harm, and that the infection is due to the dysentery 
bacillus, and that if a man will look for that carefully enough 
he will always find it. Personally, I think most cases are 



84 INFANT FEEDING (BOSTON METHODS) 

caused by the dysentery bacillus, but I do believe that a 
certain number of cases are caused by the gas bacillus. It 
is important to differentiate them because the treatment is 
different for each type. This must be done by stool cul- 
tures. Clinically, the two cannot be told apart except that 
the dysentery type is likely to be a little more severe. We 
will speak of the differentiation of the two types a little 
later. 

Let us take up the dysentery type, which is the one usually 
seen. The trouble is in the large intestine and in the lower 
part of the small intestine. There may be only a catarrhal in- 
flammation present, or there may be small superficial ulcers or 
deep ulcers. The symptoms may vary considerably according 
to the severity of the infection. The onset is likely to be sud- 
den. The stools may vary a good deal in number, as many as 
20 or 30 being passed each day. They may be very small, 
usually only small amounts of blood and mucus, pus, and slime 
being passed after the first day or two. Some cases may show 
extreme nervous systems, much resembling meningitis at the 
onset. The only way to rule out meningitis is to do a lumbar 
puncture and examine the spinal fluid. The temperature may 
vary a good deal, in some cases being very slight, in others very 
high; in most cases it is moderate, but continuous. The evi- 
dences of toxemia are usually severe, and these babies certainly 
are very sick in the great majority of cases. You have all seen 
so much infectious diarrhea that it would be a waste of your 
time to go further into the symptoms. 

Treatment. — A good many different methods of treatment 
have been used for the condition. The principle to remember 
is this : The dysentery bacillus lives upon protein food much more 
readily than it does upon carbohydrate, and the products which it 
forms from protein are much more toxic than the products from 
carbohydrate, so feed these cases on a low protein diet and a fairly 
high carbohydrate, giving the baby as much food as it can reason- 
ably take without being upset. Carbohydrate food tends to dis- 
courage the growth of the dysentery bacillus — protein food en- 
courages it. That is the principle of the treatment of cases of 
diarrhea due to the dysentery bacillus or to the streptococcus. 
It is usually best to give these cases an initial purge of calomel or 



DIARRHEAS OF INFANCY 85 

castor oil, then starve them for twenty-four hours, giving nothing 
but a 5 or 6 percent sugar solution. We used to starve them for 
as long as ten days at a time, but have stopped that, because we 
found out that they do a great deal better if they are not starved 
so long. We start the feeding by adding barley water to the 
sugar solution, and later add skimmed milk to this. Some of 
these children do not like to eat, but they have to have fluid 
and they have to have food, so feed them with a stomach-tube 
if they will not take the milk. 

The gastric symptoms are usually not severe, so there will, 
in most cases, not be much vomiting. If there is vomiting, the 
thing to do is to wash out the stomach and stop the food for a 
few feedings. 

There are no definite rules that can be laid down for the feed- 
ing of these cases. Size up each case and remember the prin- 
ciple of fitting the food to what the individual baby can take, 
keeping it rather low in protein and high in carbohydrate, and, 
especially during convalescence, low in fat, because the diges- 
tion of fat is very poor during the whole course of the disease 
and convalescence. A prominent pediatrician said last year 
that he had come to the conclusion that the best way to treat 
infectious diarrhea was to consider a case very much as a case 
of typhoid fever. This is sensible, for the dysentery bacillus is 
closely allied to the typhoid bacillus, and the pathology of the 
two conditions is somewhat the same. 

To clinch the question of feeding these cases, let us take a 
supposititious case and feed it; but remember that this par- 
ticular feeding might apply to one baby, and not to another. 

Let us say that our patient is sixteen months old, and is seen 
the first day he is taken sick, and has had four stools with blood 
and mucus. 

1. A purge — castor oil or calomel. 

2. Withdraw food for twenty-four hours, giving plenty of 
water — 8 ounces every three hours, sweetened with saccharin, 
if necessary. 

3. Start feeding with a solution of 8 percent lactose, giving 
water between each feeding. 

Lactose solution, 8 ounces every three hours. Water, 4 ounces 
between each lactose feeding. 



86 INFANT FEEDING (BOSTON METHODS) 

4. After a day of the lactose feeding add 1 percent barley 
starch to the sugar solution. Feed this for twenty-four hours. 

5. Feed lactose and starch solution, 7 ounces, skimmed milk 
1 ounce. 

Gradually increase the skimmed milk in this feeding until, 
when the baby is nearly well, he will be taking possibly this: 

Skimmed milk 6 ounces 

Barley-water 2 ounces 

Dextri-maltose 1 dram 

Soon to this can be added barley jelly, three tablespoonfuls a 
day, and if he takes this well, powdered zwieback can be given. 
The last thing to do is to increase the fat in the food, and this is 
done by substituting an ounce of whole milk for an ounce of 
skimmed milk until the baby is taking entire whole milk. 

Of course, this feeding would have to be modified for a younger 
baby, and a weaker milk would be given, but the principle is the 
same. 

As to the rest of the treatment, the most important single thing 
in the whole treatment is to keep the baby filled up with fluid. If 
; t cannot be given by mouth or by rectum, it will have to be 
given subcutaneously. This is not hard to do. Do not let these 
babies get dried out. Give them salt solution under the skin 
right away: a teaspoonful of salt to a pint of water. More 
babies die from getting dried out in this disease than from any 
other one thing. 

For excessive fever, the best treatment is baths — a sponge- 
bath of one-half alcohol and one-half water, at 80° F., or a fan 
bath, wrapping the baby in cheese-cloth, sprinkling it with water, 
and fanning him, or a cold bath at 70° F. Do not give anti- 
pyretic drugs — they are all depressants. Some babies have a 
subnormal temperature and have to be stimulated by hot-water 
bags or hot salt solution by rectum. Colonic irrigation may be 
of some value in treating the disease, and will do no harm. 
If it does not disturb the baby, it is a good idea to give one once 
a day, of normal salt solution or 4 percent sodium bicarbonate 
solution. In cases that do not clear up well and continue to 
have pus in the stools too long it is sometimes well to use a 2 
percent solution of silver nitrate for the irrigation. 



DIARRHEAS OF INFANCY 87 

Drug Treatment. — About the same may be said of the drug 
treatment of infectious diarrhea as was said for fermentative 
diarrhea. 

Purgatives. — Purgatives are indicated in the beginning of the 
disease, or during its course if the number of stools drops sud- 
denly and there seems to be a good deal of toxemia. I think it is 
extremely bad practice to give a purge every day as a routine. 

Bismuth. — Bismuth may do some good in coating over the 
ulcers in the intestine, and by tending to decrease excessive 
peristalsis. The subcarbonate of bismuth is better to use than 
the subnitrate, as there is less danger of poisoning by absorption. 

Intestinal Antiseptics. — These drugs do little good in infectious 
diarrhea, for the organisms that cause it are likely to be deep 
down in the ulcers under the mucous membrane and they can- 
not reach them. Also, large enough doses really to be valuable 
would probably kill the child. 

Opium. — The indications for opium in infectious diarrhea are 
the same as for the fermentative type. 

Stimulants. — Stimulants may be needed if the child is much 
prostrated. Strychnin, camphor, cafTein, or alcohol may be 
used. . Personally, I prefer caffein sodium benzoate given sub- 
cut aneously. 

Chloral and Sodium Bromid. — These drugs are indicated for 
restlessness. Children bear them well, and they may be given 
in good-sized doses. 

Now for the gas bacillus type of diarrhea: The treatment in 
this condition, that is, the food treatment, is different from the 
treatment of the dysentery type; the rest of the treatment is 
just the same. The gas bacillus is an organism that thrives on 
carbohydrate food, so it is absolutely wrong to feed a child with 
a condition due to the gas bacillus on carbohydrates. The gas 
bacillus cannot flourish if there is a good deal of lactic acid in the 
intestine, and these cases will sometimes do remarkably well on 
buttermilk or on lactic acid milk. I do not believe that the 
bulgar tablets are usually of much value, because they are so 
likely to be inactive, and buttermilk or lactic acid milk made 
with a liquid culture is much better. 

The rest of the treatment for this type is just the same as for 
the other types. The feeding is the only point that is different. 



88 INFANT FEEDING (BOSTON METHODS) 

Get just as much buttermilk or lactic acid milk into the child as 
possible and keep the carbohydrates low. 

Most cases of infectious diarrhea are of the dysentery type, 
so the treatment usually will be for this type. The gas bacil- 
lus can be tested for very easily by putting a small portion of 
the stool into a test-tube of milk, boiling it for three minutes, 
then stopping it up and incubating it for twenty-four hours. 
If the gas bacillus is present, the casein will be coagulated, 
will be full of holes, and will smell like rancid butter, due to the 
formation of butyric acid from the fat and sugar in the milk. 

Usually, if a "gas" case is fed on a high carbohydrate food, 
as would be done for a dysentery case, the temperature will go 
up, and the baby will be sicker, so if this happens, it is fair to 
assume that the other type of treatment, that is, with butter- 
milk, is indicated. 

How is one to tell infectious diarrhea from the fermentative 
type? Ordinarily in the fermentative form the child is not so 
ill. In this type, too, there is usually no blood in the stools, and 
there is never any pus. In infectious diarrhea there are nearly 
always blood and pus in the stools. Another thing, the tem- 
perature in fermentative diarrhea rarely continues elevated for 
more than a day or two. In infectious diarrhea it continues 
elevated for a number of days. 

Sometimes when called to a case it is impossible to tell at the 
first visit which type of diarrhea it is. Under such conditions 
it is safe to clean the baby out and starve it for twenty-four 
hours, and by this time a decision one way or the other can 
usually be made. Another condition with which infectious 
diarrhea is sometimes confused is intussusception. In this 
condition the abdomen is likely to be distended: in infectious 
diarrhea it is usually sunken. A tumor may be felt in intus- 
susception, and not in infectious diarrhea. All the symptoms 
in intussusception are likely to be more severe, and vomiting 
is prominent. The stools in the two conditions may look al- 
most exactly the same, but if there is much fecal material pres- 
ent with the blood and mucus, the case is more likely to be one 
of infectious diarrhea. 

The subject of these diarrheas is an extremely difficult one to 
present in a clear and clean-cut manner, for the reason that no 



DIARRHEAS OF INFANCY 89 

two people will say the same things about them, and I know 
perfectly well that there is plenty of room for criticism and 
difference of opinion about the things I have been telling you 
today. I have not spoken of the old-fashioned " cholera in- 
fantum" that most of you older men have seen, as it is fortu- 
nately a very rare condition today, and we practically never see 
it in Boston. 

There will be no more lectures on feeding, and I want to give 
you a very brief summary of the central ideas of the subject — a 
bird's-eye view of the whole. 

The subject of infant feeding is seemingly in chaos — what is 
believed in Boston is not believed in Chicago, what is believed 
in Berlin is not believed in New York, and so on; what is re- 
garded as gospel in one city by one group of pediatricians may 
be looked upon as of very little consequence by an equally cap- 
able group of pediatricians in another city. It is obviously not 
just or reasonable to suppose that intelligent pediatricians in 
one city do not know how to feed babies because they use 
methods which are different from those used by their confreres 
in another city, and still each group of men firmly believe that 
its own methods are the correct ones, which is only natural. I 
suppose that if the end-results of the feeding work of men of 
equal experience in the various cities, using different methods, 
were to be compared, these results would be found to be very 
similar; we get at things in different ways, but get there. 

I have endeavored to teach you Boston ideas of feeding en- 
tirely, and have paid no attention to the ideas of men who have 
different methods than ours; not because I believe that they 
are of no value, but because I believe our methods are the most 
reasonable and logical, and because it is best to save confusion 
by learning one method instead of skimming over several. 

Let us consider what the basis of the Boston method is: 

1. A baby must have a well-balanced food. 

2. He must have enough of it in fuel value. 

These two propositions are self-evident, and will be admitted 
by every one, no matter what methods of feeding he uses. 

We believe, in Boston, that most of the digestive troubles of babies 
(exclusive, of course, of such conditions as infectious diarrhea) are 
caused by an excess or a deficit of one or more of the food elements in 



90 INFANT FEEDING (BOSTON METHODS) 

the milk — fat, sugar, protein, or salts — or to a faulty digestion or 
absorption of one or more of these elements when they are perhaps 
in normal quantity in the milk. Therefore it is reasonable and 
essential to know approximately how much of each of these elements 
is in the milk that we feed to any baby. The most convenient and 
accurate way of expressing this quantity is by per cents of the various 
elements. We take into consideration the elementary composition 
of the food, and also the fuel value of the food as a whole, as ex- 
pressed in calories, or heat units. We determine what food ele- 
ment or elements are causing the baby trouble, by a study of his diet, 
himself, and his stools, and regulate the subsequent food supply by 
an increase or diminution of an element or elements of the food, or 
of the total quantity of food, according to the indications thus de- 
termined. We lay especial stress on the examination of the stools, 
macroscopic and microscopic, and believe that such examination 
helps a great deal in the proper regulation of the baby's diet by giving 
us a guide as to what he is or is not digesting. 

This is a brief exposition of the principles upon which "per- 
centage feeding" is based: there is nothing complicated about 
it; rather it tends to make a difficult subject clearer — it is 
rational, practical, and scientific at the same time, and its 
principles and practice can be grasped by any one who will take 
the trouble to give it a little thought. 



LECTURE VI 

PYLORIC STENOSIS— PYLORIC SPASM— INTUSSUSCEP- 
TION— ACID O SIS 

In the lecture today I am combining several subjects, which, 
although unrelated, will be put together into one lecture, as 
any one of these subjects alone is hardly important enough to 
you to devote a whole lecture to it. 

First, let us consider pyloric stenosis and pyloric spasm. 

Pyloric stenosis, or "congenital hypertrophic stenosis' of the 
pylorus," as it is sometimes called, is a congenital hypertrophy 
of the circular muscle-fibers of the pylorus, which causes a 
stenosis of the orifice. 

Pyloric spasm is a condition in which there is a nervous spasm 
of the pylorus which causes a stenosis. Pyloric spasm may 
sometimes complicate a true organic stenosis, or it may exist 
independently. 

PYLORIC STENOSIS 

Symptoms. — A baby, breast fed or bottle fed, will usually 
start to vomit when it is anywhere from a few days to a month 
old. This vomiting, in true stenosis, rarely begins after the 
first month. The vomiting at first may not be very severe, but 
in a few days it becomes projectile, and the vomitus may be 
shot out of the mouth to a distance of two or three feet. The 
child will vomit whatever it eats, and the vomiting is uncon- 
trollable by drugs of any sort, as can be readily understood from 
the pathology of the condition. There is no evidence of any 
indigestion, as shown by colic, diarrhea, etc., and the child is 
hungry. The child loses tremendously in weight, due to the 
fact that it gets practically no food into its intestine. The 
stools are very small in size and constipated, as little food 
goes through the pylorus. These are the important symptoms 
— the explosive vomiting, the loss in weight, and the small size 

91 



92 INFANT FEEDING (BOSTON METHODS) 

of the stools. The condition occurs with equal frequency in 
breast- or bottle-fed babies. 

There is very likely to be a considerable dilatation of the 
stomach in true pyloric stenosis; and there may also be visible 
peristalsis excited by stroking the skin over the stomach, the 
peristaltic waves running from left to right across the abdomen. 
They will not be seen unless there is something in the stomach. 
There may also be felt a small tumor — the enlarged pylorus. 
This tumor is usually midway between the tip of the ensiform 
and the umbilicus, about Y2 mcn to the right of the midline. 
In some cases it may not be felt at all, but in the majority it is 
if it is felt for when the abdominal muscles are relaxed. The 
tumor is usually about the size of a small olive, and about the 
same shape. 

Prognosis. — With proper treatment, a great many of these 
cases can be entirely cured. If the case has been let go too long, 
until the baby is exhausted and has wasted away to skin and 
bones, the prognosis, of course, is a good deal worse, and many 
will die if they are let go too long without treatment. 

Treatment. — Medical treatment is of no value in dealing with 
these cases of hypertrophic stenosis of the pylorus. Surgery is 
indicated at once, as soon as the diagnosis is made, and the 
sooner the operation can be done, the better off the child will be. 
There are two sorts of operation that may be done: first, a 
posterior gastro-enterostomy, thus short-circuiting the pylorus 
and letting the food go through the new opening, and, second, 
splitting the circular muscle-fibers of the pylorus. This last 
is considered the better operation, and most of the men are now 
using it. It takes only about twenty minutes to do, and there 
is very little shock to the baby. The treatment both before and 
after operation is important. About half an hour before opera- 
tion the baby's stomach should be washed out. After the 
operation, salt solution should be given by rectum in order to 
get plenty of fluid into the baby, and it is of great importance 
not to feed the baby very much for a considerable time after 
the operation, because the intestines are so collapsed and atro- 
phic that the baby cannot digest the food. Breast milk, of 
course, is the best food to use if it can be obtained, and this 
should be given diluted with two parts of water, in dram feed- 



PYLORIC SPASM 93 

ings, every hour. After the first twenty-four hours the amount 
and strength of the feeding can be gradually increased. When 
breast milk is not available, the next best thing is whey. When 
it is desired to increase the fat in the feeding, small amounts of 
16 percent cream can be added. The whey is given at first in 
dram feedings every hour and soon increased. 

So much for pyloric stenosis. It is not a particularly common 
condition, but important to recognize when it is seen. 

PYLORIC SPASM 

Pylorospasm is a condition of the pylorus in which there is 
nervous spasm, but no organic stenosis. It is more common 
than pyloric stenosis. Pylorospasm is likely to occur in babies 
of rather nervous temperament, who come from nervous parents. 
The symptoms are very much the same as those in pyloric sten- 
osis, but are likely to be not so severe. The difference is one of 
degree rather than of kind. Pylorospasm is much more likely 
to be seen in bottle-fed than in breast-fed babies, whereas py- 
loric stenosis occurs with equal frequency in breast- or bottle- 
fed babies. The vomiting may start immediately after birth 
in pylorospasm, but usually not until several weeks, or some- 
times not until two or three months, after birth, and it is not so 
severe as in true pyloric stenosis. The rest of the symptoms 
are the same, but not so severe as in pyloric stenosis. The 
baby loses a great deal in weight : the stools are small and con- 
stipated. The vomiting is likely to be not so explosive. The 
stomach is usually not nearly so much dilated as in true cases of 
pyloric stenosis. 

Physical Signs. — A tumor may be felt, but the tumor is longer 
and thinner than in cases of stenosis, and sometimes this tumor 
can be felt contracting and relaxing under the finger. Visible 
peristalsis is not so common as in true stenosis. It is usually 
not difficult to decide that the case is one of stenosis or spasm. 
What it must be differentiated from is simple indigestion. That 
is not hard. The vomiting in simple indigestion is not pro- 
jectile, and the symptoms are not so severe. There is no evi- 
dence of indigestion in cases of pyloric stenosis or spasm. re-Ray 
examination after a bismuth meal is also of value, as it shows 



94 INFANT FEEDING (BOSTON METHODS) 

that there is difficulty in the passage of the food through the 
pylorus. The trouble comes in differentiating stenosis from 
spasm. How is one to distinguish between these two condi- 
tions? 

First of all, spasm is rarely seen in breast-fed babies, and 
stenosis may be seen in both. The vomiting in spasm is likely 
to start a good deal later than in stenosis, and it is not so severe 
and is not so explosive. The stools are larger in spasm than in 
stenosis. A tumor may be felt in both conditions, and in spasm 
it is longer and thinner than in stenosis and it may contract 
under the finger. A tumor is much more likely to be felt in 
stenosis than in spasm. The stomach is likely to be more di- 
lated in stenosis than in spasm. Visible peristalsis is not so 
commonly seen in spasm as in stenosis. 

In mild cases of spasm the signs and symptoms of stenosis, 
such as palpable tumor, visible peristalsis, extremely explosive 
vomiting, etc., are not seen. In severe cases of spasm the signs 
and symptoms may be almost identical with those of stenosis, 
and the differentiation may be impossible. Severe cases of spasm 
must be treated in the same way as cases of stenosis. 

Treatment. — A great deal may be done for some cases of 
pylorospasm by proper treatment. The most important thing 
is the regulation of the food supply. Breast milk is indicated 
if it can be obtained. A food low in protein should be given, 
adding sodium bicarbonate or lime-water to prevent the forma- 
tion of large curds, for these pass a narrow pyloric opening with 
great difficulty. Feed a food low in protein and fat and high 
in sugar. Sometimes hot applications to the abdomen before 
the feeding are of value. The drugs indicated are atropin and 
opium in some form a half -hour before each feeding. Washing 
out the stomach several times a day with sodium bicarbonate is 
also of value. Sometimes, no matter what treatment is used, 
operation will have to be resorted to. If medical treatment has 
been tried faithfully for a considerable time and the child does 
not get better, the case must be operated on. The operation is 
the same as for pyloric stenosis. 



INTUSSUSCEPTION 95 



INTUSSUSCEPTION 

I want to talk now about intussusception. What is intus- 
susception? Intussusception is an invagination of one part of 
the intestine into another part. This is most likely to be an 
ileocecal invagination, but may occur in any part of the intes- 
tine. It is most often seen in small babies and children, and is 
a very important condition to recognize immediately when it 
is seen. The etiology is rather obscure. A certain number of 
cases will be seen during the course of a severe diarrhea, and a 
few cases may be due to trauma. Some are due to kinks or 
malformations in the intestine. It is also occasionally seen in 
severe cases of purpura. 

Symptoms. — The onset is usually sudden. A previously 
well baby is taken with severe abdominal pain and vomiting. 
The stools consist of blood, mucus, and fecal material. After 
a few stools have been passed they no longer contain fecal 
material, but only blood and mucus, and they are small in 
size. The symptoms become very severe, with considerable 
shock and prostration. There may be a fairly high tempera- 
ture. In a good many cases a sausage-shaped tumor may be 
felt, usually in the left side of the abdomen, or if it cannot be 
felt through the abdominal wall, it may be felt by rectum. 
Sometimes this tumor may be seen, the intussusception pro- 
jecting out of the rectum. In Dr. Holt's series the tumor was 
felt in 86 percent of the cases. 

Sometimes the diagnosis is difficult, especially in the sub- 
acute cases, where the symptoms are not so marked. The 
main thing intussusception must be distinguished from is in- 
fectious diarrhea, and a good many cases of intussusception 
are wrongly diagnosed as infectious diarrhea. Infectious diar- 
rhea does not usually come on so suddenly, and in this con- 
dition the abdomen is likely to be sunken. In intussusception 
it is often distended. One cannot tell much from the stools, 
because they may look very much the same in both conditions. 
The temperature is likely to be higher in infectious diarrhea than 
in intussusception. Not much can be told from the condition 
of the child, because it may be extremely prostrated in both 
conditions; but usually there is more shock in intussus- 



96 INFANT FEEDING (BOSTON METHODS) 

ception — it is not so likely to be in most cases of infectious 
diarrhea. 

Treatment. — Operation right away! As soon as a diagnosis 
of intussusception is made, call in a surgeon and have him oper- 
ate immediately. Often a delay of six or eight hours in operat- 
ing will cost the life of the child, because the operation should be 
done when the child is in as good condition as possible. It is 
true that some cases of intussusception will reduce themselves 
spontaneously, and that others may be reduced by the injec- 
tion of water into the bowel. This is altogether too uncertain 
to be depended upon, however. The prognosis is not a good 
one. In about 50 percent of the cases the child dies. The 
prognosis depends, more than anything else, upon how soon the 
child is operated upon after the diagnosis is made. 

The following three histories, taken from the Children's 
Hospital records, may serve to give you a better idea of the 
symptoms : 

Case 1. — C. 0., seven years. Five days ago an eruption was 
noticed on legs and thighs, which was composed of areas the 
size of the tip of the little finger, level with the skin and of a 
purplish color at first, changing to brownish red. 

These spots faded slowly and disappeared almost entirely in 
three days. At this time the legs and feet were swollen (typical 
purpura). 

Two days ago a diarrhea began, which was composed entirely 
of fecal matter at first, but in a few hours was practically all 
blood, very little mucus, and no fecal matter. Has been vom- 
iting a great deal of greenish-yellow, liquid mucus, occasionally 
blood streaked. Moderate pain in the right abdomen. 

Hasty examination shows a large tumor in right lower quad- 
rant. Abdomen distended and tympanitic; general condition 
fair. Transferred surgical and operated. Intussusception found. 

Case 2. — D. M., eighteen months. (Illustrating the subacute 
type of case.) Three weeks ago the child fell from a chair to 
the floor. His father says that when he picked up the baby he 
felt a lump on the abdomen which soon afterward disappeared. 
The child played and acted normally the rest of the day, but 
that night began to vomit. A doctor was called, and after he 



INTUSSUSCEPTION 97 

had taken a rectal temperature the baby passed some blood and 
mucus. An enema given immediately afterward gave no re- 
sults. Since then he has vomited occasionally. The stools 
are dark, with some mucus and blood. 

One week ago he had another more severe vomiting attack. 
Bowels have moved twice daily for the past week — dark in 
color. No blood noted. One day ago the stool was dark, with 
streaks of fresh blood. Today he had four stools, dark in color, 
with considerable mucus, but no blood. 

Has been vomiting all day and has complained of pain in 
stomach region. 

P. E.: In fair general condition. Abdomen: Full, rounded, 
tense, tympanitic; muscular resistance is general, but more 
marked on left side. Some tenderness on left. No tumor felt. 
Rectal negative. 

Day After Admission. — Child has appeared fairly comfort- 
able since admission, but has complained of moderate abdominal 
pain at times. Has vomited all food taken. One stool ob- 
tained contained mucus and blood. P. E. : In the abdomen is 
felt a definite, sausage-shaped tumor in left iliac region. 

Rectal examination shows resistance on left. 

Transferred surgical — operated, and intussusception found. 

Case S. — R. M., seven months. Eight days ago he began to 
draw up his knees and scream. A doctor who was summoned 
called it " stoppage of the bowels." He administered a sup- 
pository without result. He then gave an enema and got a 
stool. Castoria was then given and normal stools followed. 

Three nights ago he began to vomit. He vomited ten times 
during the next day and has vomited frequentl} r since — not 
projectile, no bile or blood. Last vomitus was at 1.15 this 
afternoon. This " looked and smelled like a bowel move- 
ment." Bowels moved five times yesterday and at 2.30 this 
morning. No blood in stools. Mucus in stools yesterday and 
the one this morning was mostly mucus containing a little fecal 
matter. 

P. E. : In good condition. Abdomen negative. Rectal nega- 
tive. Next day vomited continuously all day; twice had fecal 
vomiting. 

Transferred surgical and operated. Intussusception found. 
7 



INFANT FEEDING (BOSTON METHODS) 



ACIDOSIS 

Acidosis is a condition which has been discussed a great deal 
of late ; many investigators are working on problems connected 
with it; but its causation and exact nature are still very im- 
perfectly understood. I can hope to do no more than give you 
a very superficial view of this complicated subject, and, as I 
said before, when discussing the diarrheas of infancy, it is hardly 
fair to speak dogmatically in discussing such a subject; but I 
shall do so for the sake of clearness. 

What is acidosis? Normally the blood is slightly alkaline in 
reaction. This alkalinity is maintained in the body by a num- 
ber of factors. When the degree of alkalinity becomes lessened 
and the blood more nearly approaches a neutral reaction, a 
condition of acidosis results. Acidosis is thus a diminution of 
the alkalinity in the blood. 

What may cause a diminution of the alkalinity of the blood? 
First of all, there may be an increased acid production, such as 
occurs in diabetes or in starvation. This increased production 
of acids occurs when fat is being broken down in the body, es- 
pecially when carbohydrate food is withdrawn and the fat 
supply of the body is broken down and imperfectly oxidized. 
These "acid bodies," as they are called, are acetone, diacetic 
acid, and betaoxybutyric acid. 

Another way in which acidosis is produced is by a decrease in 
acid elimination. The normal acidity of the urine is due to 
acid sodium phosphate in solution. If there is no excretion or 
very little excretion of this substance, due to anuria, and it is 
retained in the body, it tends to produce acidosis. This con- 
dition may occur in the diarrheal diseases of infants when there 
is anuria. 

A loss of alkali from the body may help to produce acidosis. 
This may occur in fermentative diarrhea, where there is a tre- 
mendously acid condition in the intestine. The alkali reserve 
of the body is drawn upon to neutralize this acidity, and a large 
amount of alkali may be lost in the stools in this way. These 
three causes may singly or together produce acidosis. 

As Dr. Marriott, of Johns Hopkins, has said, "acidosis" is a 
term which is used very loosely. It is used by most people to 



ACIDOSIS 99 

indicate that a child has acetone or diacetic acid in the urine. 
Strictly speaking, it is true that a mild acidosis is present when 
these substances are found in the urine, but they will be found in 
the urines of many children who have no clinical signs of acido- 
sis, and should be looked upon rather as a symptom than as 
anything else, and no treatment is indicated, nor is there cause 
for worry unless clinical symptoms of acidosis are present in 
addition to the presence of acetone in the urine. It is surpris- 
ing, in a routine examination of the urines from many sick 
children, to see how many of these contain acetone. Ace- 
tonuria may be regarded in much the same way as fever is: 
we do not need to worry about fever unless it is excessive: we 
do not need to worry about acetonuria unless it is severe and 
has other symptoms of acidosis along with it. Acetone will be 
found in the urines of most children ill with acute fevers. What 
are the tests for acetone and diacetic acid in the urine? They 
are both simple. 

Tests for Acetone and Diacetic Acid in Urine. — Acetone. — To 
5 c.c. of urine in a test-tube add a small crystal of sodium 
nitroprussid and a few drops of strong acetic acid, and shake. 
Make alkaline with ammonium hydroxid. A purple color indi- 
cates acetone. 

Diacetic Acid. — To 5 c.c. of urine in a test-tube add an excess 
of a 10 percent solution of ferric chlorid. A dark brownish-red 
color indicates diacetic acid. After the taking of certain drugs, 
especially aspirin, such a reaction may be obtained in the urine, 
and the color does not disappear on heating. The red color, if 
due to diacetic acid, disappears on heating. 

In What Conditions is Acetone Likely to be Found in the 
Urine? — Starvation. — When a person takes little or no food for 
a day or two, there is likely to be acetone in the urine, due to 
the breaking down of the body fat which is being used for food. 
This is probably one reason why acetone is so often found in 
the urines of fever patients : they eat very little. This type of 
acetonuria is also likely to be seen after surgical operations 
upon children; whether it depends upon starvation alone, or 
whether other factors as well enter into its production, is not 
certain. 

Diabetes. — Acetone and diacetic acid occur very frequently 



100 INFANT FEEDING (BOSTON METHODS) 

in the urines of diabetic patients, as you all know. This is 
probably due to the breaking down of ingested or body fat. 

Fever. — Acetone is likely to occur in the urine of a patient 
with any febrile disease. Whether this is due to the fact that 
these patients eat little, or whether it may be due to some pe- 
culiar effect of fever on the body metabolism, is not certain. 

The three types of acetonuria that we have been speaking of 
are not peculiar to childhood — they do not interest us particu- 
larly. 

Types of Acidosis Peculiar to Children. — Diarrhea. — There 
may be an acidosis accompanying certain diarrheas of infancy. 

"Recurrent" Vomiting. — In cases of so-called recurrent vom- 
iting in children there is usually acetone in the urine, and some- 
times other evidences of acidosis. In some cases this is prob- 
ably present secondary to the vomiting, and is due to the fact 
that the child eats nothing; in others it may be primary, and 
the vomiting be due to acid intoxication, the whole disturbance 
being caused by some peculiar derangement of metabolism of 
which we know little. 

Severe Acid Intoxication; "Epidemic " or Periodic. — Let me say 
at the start that there is really no such thing as true epidemic 
acidosis. There is a severe acidosis which occurs in epidemics 
secondary to influenza or other nasopharyngeal or respiratory 
infection, but the epidemic is not of " acidosis" itself. This is 
the most interesting type of acidosis, the most severe, and the 
one which I want to talk of particularly. 

How is one to tell, when acetone is found in the urine, whether 
or not the condition is severe enough to worry about or to call 
for any particular treatment? The amount of acetone and 
diacetic acid in the urine is not a good index of the severity of 
the acidosis, for severe acidosis may occur with very little ace- 
tone in the urine, or mild acidosis with a good deal of acetone 
in the urine. There are a number of methods of determining 
the degree of acidosis and expressing it quantitatively, the two 
most important of which are analyses of the alveolar air and of 
the blood itself. I merely mention these, as they are hardly 
practical for the average physician to use. 

For practical purposes, if a child has acetone and diacetic 
acid in the urine, is restless and vomits, and has deep, labored 



ACIDOSIS 101 

breathing without cyanosis, one may decide that there is acidosis 
present and start immediate treatment. 

Certain children seem to be subject to periodic attacks of acid 
intoxication, and may have an attack every few months. I 
well recall one child of five who was in the Children's Hospital 
with acidosis six times in ten months. She was extremely sick 
in each attack, with identical symptoms each time she entered. 
These periodic attacks of acid intoxication are similar to the 
" epidemic" cases. 

What is the etiology of the condition? Some of the cases 
seem to be secondary to acute indigestion, some secondary to 
exhaustion or severe nervous disturbance; the child's equilib- 
rium is very unstable, and its body chemistry can be easily up- 
set. It is difficult to explain the epidemic cases on any other 
basis than that of an infection — the epidemic in Boston last 
spring occurred when there was a great deal of respiratory in- 
fection of various sorts about, and in many of the cases the ton- 
sils or nasopharynx was inflamed and swollen. Personally, I 
believe that this epidemic type of acidosis is secondary to some 
infection of the tonsils or nasopharynx, probably with the in- 
fluenza bacillus or the streptococcus. 

The usual story of a case is about as follows : 

A child is taken rather suddenly with uncontrollable vomit- 
ing — it may or may not have had a slight fever with naso- 
pharyngitis previously. There is usually no diarrhea. The 
skin is dry and hot, with moderate fever; the abdomen is 
sunken, and if the condition goes on, the eyes may be sunken, 
due to the loss of fluid from the vomiting, which is very severe 
and may be uncontrollable : usually nothing can be kept on the 
stomach. The urine is very scanty and highly colored, and is 
loaded with acetone and diacetic acid. There is likely to be 
excessive thirst. The lips are of a bright, . cherry-red color; 
this is quite a striking characteristic of the condition. The 
respiration is deep, rapid, and labored, without cyanosis, and 
there is a peculiar sweetish odor to the breath — the odor of 
acetone. The child may be very restless or may be in a stupor. 

These children are extremely sick, their condition is a precarious 
one, and vigorous and prompt treatment is indicated. 

Treatment. — Nursing. — An extremely important part of the 



102 INFANT FEEDING (BOSTON METHODS) 

treatment is to have a good nurse, or an intelligent, capable 
mother, who can be with the child ; these children need to have 
constant attention. 

Catharsis. — If the child can retain anything on the stomach, 
give it a cleaning out with calomel or castor oil; if it cannot, 
empty the intestine from below with a suds enema. 

Soda. — Whether or not the child recovers depends a great 
deal upon whether enough alkali can be gotten into it to neutral- 
ize the acidosis and to bring back the blood to a normal alkalin- 
ity. If the urine can be made alkaline in the first twenty-four 
hours, the child will probably get well; if it cannot be, it may 
get well or may die. This is where a good nurse comes in — she 
must be at the child every minute to get it to take alkali. The 
alkali may be given by mouth, intravenously, or by rectum. 
You will not in most cases be able to depend upon getting it 
into the child by mouth, as the vomiting is so severe, but mouth 
administration should be tried at first. The dosage depends 
upon the size of the child and the severity of the acidosis, but 
should always be liberal. Thirty grains every two hours to a 
child of three years is not too much. If it has to be given by 
rectum, 30 drops a minute of a 10 percent solution is suitable. 
If it is given intravenously, a 4 percent solution is used, and the 
amount to be injected depends, of course, upon the size of the 
child. 

Sodium bicarbonate should not be given subcutaneously as 
it causes sloughing. Do not give too much soda; there is reason 
in everything, and I have seen a child who died more from too 
much soda than from acidosis. 

Fluid. — It is of extreme importance to get plenty of fluid into 
children with acidosis, to prevent them from getting dried out, 
and to keep the kidneys active, to remove acid from the system. 
They are usually very thirsty. A scanty urinary secretion is 
a bad sign. Fluid is best given subcutaneously in the form 
of normal salt solution. 

Food. — Next in importance is food. The stomach is so irri- 
table that it is probable that little food will be retained at first. 
It is useless to try to give solid food. The best food is skimmed 
milk, with dextrose added to 10 percent. Dextrose is indicated 
in acidosis in the same way it is in diabetic coma : if easily avail- 



ACIDOSIS 103 

able, carbohydrate can be furnished to the body: it tends to 
stop the pathological breaking down of fat and acid production. 
Dextrose, if not well borne by the stomach, may be given in- 
travenously in a 2 percent solution, subcutaneously in a 5 per- 
cent solution, or by rectum in a 10 percent solution. 

As convalescence progresses the food should be largely car- 
bohydrate in character, with very little fat. 

Opium. — Opium in some form, usually morphin subcutane- 
ously, should be given up to the limit of tolerance, as one of the 
most desirable things in treatment is to stop the vomiting if 
possible and to quiet the restlessness, which may be extreme. 

Stimulants. — If stimulants are needed, caffein or camphor in 
oil may be used. 

This condition is an extremely severe one, but a good deal 
can be done for it by prompt and thorough treatment. 



LECTURE Vn 
RICKETS— SCURVY— SPASMOPHILIA 

I shall speak today of three diseases of metabolism: rickets, 
scurvy, and spasmophilia, or tetany. 

RICKETS (RACHITIS) 

Definition. — Rickets is a constitutional disease, probably 
caused mostly by prolonged error in diet, bringing about a faulty 
metabolism. Its chief manifestations are in the bones. 

Pathology. — The chief lesions of rickets are in the bones. 
There is an overgrowth and softening of the cartilaginous layer 
between the epiphysis and shaft of the long bones. This area 
is markedly hyperemic, from the ingrowth of small blood- 
vessels, and the deposition of lime salts is much decreased in 
both the epiphyses and shafts of the bone, thus resulting in 
delayed ossification and soft bone. 

The outer layers of the shaft of the bone are thick, soft, and 
hyperemic, with a lessened deposition of lime, and the centers of 
ossification in the epiphyses of the bone are in the same con- 
dition. 

The essential thing to remember is that there is not enough 
lime deposited in the bone, and this results in a soft bone, which 
is easily distorted in shape or actually broken. Rickets may 
last anywhere from three to twelve months, the process in the 
bone going through several stages, resulting in a permanent 
enlargement at the epiphyses, with or without a deformed shaft. 

Let it be distinctly understood that many children one sees 
with rachitic deformities, such as bow-legs, enlarged epiphyses, 
etc., have not actual rickets — the rachitic process may have en- 
tirely subsided, and what is seen is the end-result of the process. 
In many cases a child who has had severe rickets may be left 
with little or no deformity. 

104 



RICKETS — SCURVY — SPASMOPHILIA 105 

Etiology. — The etiology of rickets is probably due to a num- 
ber of factors. 

It is much more likely to be seen in artificially fed babies than 
in breast fed ; it is most likely to be seen between the sixth and 
eighteenth months, but may be seen before or after this. It is 
much more common in the thickly populated districts of large 
cities than it is in the country, and negroes and Italians seem to 
be particularly prone to it. It is especially likely to be seen in 
children who have had a good many digestive troubles, who 
have never seemed able to do well as regards their feeding, and 
who have been tried first on one food, then on the other, es- 
pecially the proprietary foods. The end-result of all these 
conditions is that not enough calcium is deposited in the bones, 
and this is one particular thing that the various theories of the 
etiology of rickets try to explain. All cases cannot be due to a 
lack of calcium in the food, for most babies fed on modifications 
of cow's milk ingest three or four times as much calcium as is 
actually necessary for them. It must, therefore, be due to a 
faulty assimilation of calcium. How can this be brought about? 
One way that it can certainly be brought about is by an in- 
tolerance for fat, where a large amount of the higher fatty acids 
are present in the intestine; the calcium in the food combines 
with these acids to form insoluble calcium soaps, which cannot 
be absorbed and are excreted in the feces, thus resulting in a 
great loss of calcium. Another cause is the taking of a food 
which contains too little calcium, as a very weak breast milk 
or a dilute condensed milk formula. Personally, I believe that 
most cases of rickets can be explained by one or the other of 
these errors in diet. 

For practical purposes, leaving all theory aside, we can say 
that rickets is caused by faulty hygiene and poor nutrition. 

Symptoms and Signs. — These are fairly characteristic, though 
at the outset they may be rather indefinite. The baby may be 
irritable, may not gain in weight, may be especially restless at 
night, and may sweat a good deal about the head. When the 
disease is developed, it is absolutely unmistakable. The head 
in rickets is likely to be square, with very prominent frontal 
bones. The anterior fontanel closes a good deal later than it 
should. Normally, the fontanel closes at about the nineteenth 



106 INFANT FEEDING (BOSTON METHODS) 

month; in rickets, usually a good deal later. There may be 
soft spots in the skull, called "craniotabes." The sutures of 
the skull may remain open a good deal longer than usual. The 
dentition is usually delayed: a baby of eighteen months may 
have only as many teeth as a baby of eight or ten months. 

The chest may be flattened laterally, giving the so-called 
"Harrison's grooves," a concavity of the ribs on the sides in- 
stead of a convexity. Or, in some cases, you may have seen 
the "pigeon-breasted" chest, with the sternum ver}^ prominent. 
A characteristic thing, pathognomonic of rickets, is the so- 
called "rosary," which is a beading of the ribs due to enlarge- 
ment at the junction of the ribs and costal cartilages. These 
nodules may be as small as peas or as large as marbles. 

The changes in the long bones also are important; there 
may be a great deal of bowing of the bones of the arms and also 
of the legs, which sometimes may be extreme in the more severe 
cases. The epiphyses at the wrist are usually enlarged, as are 
those at the ankles and knees. There may be a severe kyphosis 
of the spine in a good many cases. The clavicles also may be 
tremendously deformed. There may be in many of the long 
bones multiple fractures, due to the extreme softness. 

General Appearance. — The children are usually small, poorly 
nourished, underdeveloped in every way. The abdomen is 
prominent, and the umbilicus is often everted. The spleen and 
liver are enlarged. These children are usually anemic, some- 
times to an extreme degree, and are irritable and nervous. 
Laryngismus stridulus or spasmophilia may be associated with 
rickets. 

Diagnosis. — The diagnosis is not at all difficult; an extreme 
case can hardly be mistaken for anything else. The stage of 
the process may be told by the appearance of the bones as shown 
by the #-ray. 

Treatment. — The treatment of rickets consists mainly of 
hygiene, sunlight, fresh air, and proper feeding. More can be 
accomplished by this method of treatment than by any other. 
It is a question whether or not drugs do any good; the drugs 
usually given are phosphorus and cod-liver oil. I do not be- 
lieve in giving the latter, because the fat digestion is usually so 
poor. Phosphorus may do some good, as it has been shown that 



RICKETS SCURVY SPASMOPHILIA 107 

the administration of phosphorus to rachitic children favors the 
retention of calcium. The dose of phosphorus for a baby is 
tIt grain, given from one to three times a day. It may be 
given in the form of pills, or as the "phosphorated oil" of the 
pharmacopeia, a minim of which contains about rfs grain of 
phosphorus. Iron is indicated if the children are anemic, and 
the best preparation to use is the saccharated oxid of iron, or 
"Eisenzucker," as it is sometimes calledo This may be given 
in doses of three grains three times a day to babies a year 
old. 

The treatment of the deformities of rickets is, of course, 
orthopedic. 

Rickets is a disease that does not in itself threaten life. The 
two worst things about it are that babies with rickets have very 
little resistance to infection, especially pulmonary infection, 
and that in many cases permanent deformities result from the 
rachitic process. 

SCURVY 

Scurvy is the next subject we take up. Infantile scurvy is the 
same disease as scurvy in the adult. It is not the same disease 
as rickets, and has nothing to do with it, although years ago 
cases of scurvy used to be called " acute rickets." It is often 
associated with rickets, however, in about half the cases. 

Scurvy is a food disease. It may be defined as a disease of 
metabolism dependent on some prolonged deficiency in the 
diet, the chief manifestation of which is hemorrhage, especially 
under the periosteum of the long bones of the leg. It is usually 
seen in babies from six to sixteen months of age. 

A great many cases of scurvy will be found among babies fed 
on pasteurized or sterilized milk or on proprietary foods. It 
does not often develop in children fed on raw milk or on the 
breast. The reason probably is that the development of scurvy 
depends on the absence of vitamins in the diet. These are 
chemical substances in the milk necessary for the baby to have, 
but which are destroyed by heat. Therefore, the boiling of 
milk destroys the vitamins and predisposes to the development 
of scurvy. However, the etiology is not entirely clear. There 
are a great many contradictory features in the etiology of the 



108 INFANT FEEDING (BOSTON METHODS) 

disease, for scurvy may develop in babies fed on raw milk or 
on breast milk. 

A number of years ago the American Pediatric Society in- 
vestigated a large series of cases of scurvy, with special regard 
to the etiology, and the only definite conclusion that they could 
arrive at was that the more a food differs from a baby's natural 
food, breast milk, the more likely is its use to be followed by 
scurvy. 

A tabulation of the cases they investigated is as follows: 

12 cases fed on breast milk. 



5 " 


" " raw cow's milk. 


20 " 


" " pasteurized milk. 


60 " 


" " condensed milk. 


107 " 


" " sterilized milk. 


214 " 


" " proprietary infant foods 



You can see from this that scurvy may develop in a baby 
fed on any sort of milk, but that it is much more likely to be 
seen in babies who have been fed on sterilized milk or on one 
of the proprietary foods. We do not nee'd to go into the etiol- 
ogy of scurvy any further; it is enough for our purposes to say 
that it is probably caused in most cases by feeding a baby on a 
prolonged diet which lacks some element or elements necessary 
for its proper nutrition: that these elements probably are 
"vitamins" and are destroyed by heat, which explains why 
babies are so much more likely to develop scurvy when they 
are fed on sterilized rather than on raw milk. 

Pathology. — The most prominent feature in the pathology of 
scurvy is the tendency to hemorrhage. This hemorrhage oc- 
curs especially under the periosteum of the bones, and is much 
more often seen in the bones of the lower extremities than in 
any other location. Sometimes the hemorrhage may be very 
large, and may cause tremendous swelling of the legs; the 
clotted or partly organized blood may feel very hard, and may 
sometimes be mistaken for a bony tumor. Although there may 
be considerable hemorrhage under the periosteum adjacent to a 
joint, the joints themselves are but very rarely affected. There 
may be hemorrhage from the kidneys, or more rarely into the 
skin, into the intestine, or back of the eyeball. A hemorrhagic 
condition of the gums, especially the upper gums, is common. 



RICKETS — SCURVY — SPASMOPHILIA 109 

Symptoms. — The symptoms of scurvy are fairly character- 
istic. The onset is usually gradual, and the first symptom is 
likely to be tenderness of the legs. The usual story is about 
this: a baby who has been previously well, and who perhaps 
has been walking about, becomes fretful and irritable, stops 
walking, and cries when its legs are moved or touched. In 
many early cases these may be the only symptoms, and slight 
as these symptoms may seem, they are enough upon which to 
make a positive diagnosis of scurvy, provided other conditions are 
ruled out. There may be a great deal of swelling of the legs, 
and they are usually extremely tender, the slightest touch caus- 
ing the baby severe pain. The position these babies lie in is 
characteristic, with outward rotation of the thighs and eversion 
of the feet. The appearance of the gums is characteristic: 
in babies who have teeth the gums around the teeth, especially 
the upper ones, are swollen, soft, dark reddish purple in 
color, and bleed very easily. Blood may occur in the urine in 
some cases — sometimes it may be the first symptom: the 
urine may be bright red, or it may be recognized by microscopic 
examination. If a small baby has blood in its urine, scurvy 
should always be considered. The pain, the tenderness and 
swelling of the legs, the purple, swollen gums, and the hema- 
turia are the most important points in the diagnosis of scurvy. 
Of these, pain in the legs is the most important symptom. 
All these signs may not occur together, but when they do, the 
diagnosis of scurvy is very easy to make. 

Rarely there may be hemorrhages into the skin and into the 
intestine, or in the orbit, causing a protrusion of the eyeball, 
but these are not the ordinary signs to be looked for. 

There is usually no particular digestive disturbance with 
scurvy. There may be fever, in most cases not very high. 

Prognosis. — If the case is not treated and lingers on for several 
months, the child will finally die from toxemia and malnutri- 
tion; if it is treated right, it will be well in a few days. 

Diagnosis. — There are a number of things from which scurvy 
must be differentiated. One of the most common mistakes is 
to call scurvy acute rheumatism. These points should help in 
the diagnosis. Acute rheumatism is excessively rare in chil- 
dren under two or three years old; in scurvy the other signs, 



110 INFANT FEEDING (BOSTON METHODS) 

sponginess of the gums, etc., are likely to be present, and the 
swelling and tenderness are especially in the shaft of the bone, 
and not around the joint, as they would be in rheumatism. 

Sometimes scurvy may be mistaken for poliomyelitis or in- 
fantile paralysis, on account of the pseudoparalysis of the legs, 
but usually in infantile paralysis there is not nearly so much 
tenderness, and the knee-jerks are not absent in scurvy as in 
infantile paralysis. Also, there is no swelling of the legs in in- 
fantile paralysis. 

Occasionally, the severe epiphysitis sometimes seen in cases 
of congenital syphilis will be confused with scurvy, but usually 
there are other signs of syphilis present, such as the skin lesions, 
enlarged spleen, etc., which will aid in the diagnosis. 

I don't think there is any doubt but that a great many cases 
of scurvy are overlooked. The tenderness of the legs is enough 
to suggest a diagnosis in a great many cases, even if there are 
no other signs or symptoms present. 

Treatment. — The proper treatment of scurvy is important 
and it is a very satisfactory treatment. There are few dis- 
eases that will respond to treatment so well as scurvy does. 
It is remarkable what can be done for a child who is treated 
properly. The treatment is to give him fresh fruit-juice or 
fresh vegetables. The best fruit to use is orange. If oranges 
cannot be obtained, use scraped potato or scraped apple. Fruit- 
juices are better than vegetable juices. Give the orange-juice 
in tablespoonful doses about an hour before the feeding — four 
doses a day. The idea of the treatment is to supply the missing 
vitamins by giving fruit or vegetable juices, which contain these 
substances. The peculiar thing is that the vitamins in orange- 
juice or vegetable juice cannot be destroyed by cooking, as the 
vitamins in milk can, so mashed potato is a fairly satisfactory 
antiscorbutic. Most cases of scurvy can be cured in about a 
week or ten days; many cases in three or four days. In treat- 
ing a child who has scurvy do not have his milk pasteurized or 
sterilized if you can get good milk. When a child is being fed 
on sterilized or pasteurized milk or on proprietary foods, it is 
better to give it small doses of orange-juice right along, because 
it acts as a prophylactic and prevents the development of 
scurvy. 



RICKETS — SCURVY — SPASMOPHILIA 111 

It is interesting to note what Thomas Sydenham, the great 
English physician, writing about 1660, considered his favorite 
prescription for scurvy. He says: "The patient ought to use 
the following medicated beer for common drink: . 

" Take of the root of horseradish, fresh gathered, two drachms; 
twelve leaves of scurvy grass, six raisins stoned, and half a 
Seville orange; bruise and slice the ingredients, and infuse 
them in a large glass vessel, well corked, in a quart of small beer. 

"Let six bottles of this beer be made at one time, and in a 
few days, before it be finished, six more, and renew them for the 
future in the same manner." 



SPASMOPHILIA (TETANY) 

Spasmophilia, or tetany, is a condition caused by a distur- 
bance of metabolism, probably connected in some way with the 
calcium metabolism. It may occur in adults or in children of 
any age, but it is most common in bottle-fed babies from six 
months to two years of age. It is rare in breast-fed babies. 
It is manifested by extreme nervous irritability with tonic 
muscular spasms, especially of the hands and feet, with or 
without general convulsions. It is not the same thing as tetanus, 
and bears no relation whatsoever to it. It is frequently as- 
sociated with rickets. 

Etiology. — In adults tetany may be caused by removal of the 
parathyroid glands, minute bodies, four to six in number, which 
lie near the thyroid gland. In the tetany of babies there may 
sometimes be found small hemorrhages into the parathyroid 
glands at autopsy, but it has never been clearly shown just what 
connection the parathyroids have with it, and it is probable that 
they have little to do with the ordinary spasmophilia seen in 
small babies. 

A great deal of experimental work has been done with tetany 
in the last few years, and various theories have been advanced 
to explain it. The most reasonable explanation I have ever 
seen is one advanced by Drs. Brown and Fletcher, of Toronto, 
about a year ago, based on a considerable number of investi- 
gations conducted by them. 



112 INFANT FEEDING (BOSTON METHODS) 

In the body, to preserve the proper nerve equilibrium, there 
must be present, on the one hand, calcium and magnesium, on 
the other hand, sodium and potassium, in fairly constant ratio. 
Calcium and magnesium are nerve sedatives ; sodium and potas- 
sium are nerve excitants. The idea is that spasmophilia is due 
to an abnormal storing up of sodium and potassium in the body, 
in excess of the calcium and magnesium, with a resulting hy- 
perirrit ability of the nervous system. 

This theory is borne out by many chemical data which I 
do not need to go into. 

Spasmophilia almost always occurs during the winter months : 
rarely, in the summer. This theory explains the seasonal oc- 
currence by the fact that babies are very likely to have diar- 
rhea during the summer, with a resulting loss of sodium and 
potassium, for it is well known that in the ordinary acid diarrhea 
due to sugar fermentation there may be a considerable loss of 
these elements. Thus, in the summer there is no chance for the 
storing up of sodium and potassium, and so no spasmophilia, 
whereas in the winter months, when babies are not so likely to' 
have loose bowels, there is more chance for the storing up of 
these elements, and consequently more spasmophilia. This is 
borne out by clinical experience, for it is well known that con- 
stipated babies are more likely to develop spasmophilia than 
are those who have a tendency to looseness of the bowels. So 
much for the theory. 

Diagnosis. — Spasmophilia is not at all an uncommon con- 
dition, and is easy of diagnosis if one has seen previous cases 
and is on the watch for it — if one is not, it may be very easily 
overlooked. 

The chief characteristic of the condition is a nervous hyper- 
irritability. This is manifested by peculiar spasms involving 
especially the hands and feet. Another manifestation of the 
condition is "laryngismus stridulus." The spasms of tetanj^ 
are quite characteristic: the hands and feet are held in posi- 
tions peculiar to the disease. 

The wrists are flexed ; the hand has a tendency to be drawn 
to the ulnar side; the fingers are partially flexed at the meta- 
carpophalangeal joints, and the thumb is drawn over across 
the palm of the hand toward the little finger. The feet are 



RICKETS — SCURVY — SPASMOPHILIA 113 

extended on the leg as far as possible, and the toes are flexed on 
the foot. A description of these positions brings little to the 
mind, but when once a typical "carpopedal" spasm, as it is 
called, has been seen, it will never be forgotten. 

In some of the cases there will be generalized convulsions; 
in others, only the carpopedal spasm. The spasms may occur 
a few times a day or be nearly continuous. The carpopedal 
spasm is practically always bilateral. The duration of a spasm 
varies a good deal: ten or fifteen minutes is a fair average. A 
good deal of pain may be associated with the spasm, especially 
if one tries to unclinch the fingers of the baby's hand. 

An attack of tetany may usually be diagnosed by the char- 
acteristic position of the hands and feet during a spasm, but 
there are three other signs which are of importance : 

Chvostek's Sign. — This consists of a quick contraction of the 
muscles of the face, especially of the mouth muscles, when the 
facial nerve is lightly tapped. This occurs in children with 
spasmophilia, but not in normal children. 

Trousseau's Symptom. — If the upper arm of a baby with 
spasmophilia is squeezed so as to compress the large nerve- 
trunks for a few moments, a typical carpopedal spasm results. 

The Electrical Reactions. — This is the most scientific and 
accurate way of diagnosing spasmophilia, but is hardly prac- 
tical for general use. The muscles in babies with spasmophilia 
require much less electricity to be applied to them to cause a 
contraction than do the muscles of a normal baby. By one 
familiar with the method the exact amount of electricity neces- 
sary to cause the contraction of a muscle can be determined; 
if this amount is less than the normal, the baby probably has 
spasmophilia. 

The characteristic electrical reactions always occur in cases 
of spasmophilia — Chvostek's and Trousseau's signs ma}^ or 
may not. Of these last two signs, Chvostek's is the more 
valuable. 

Prognosis. — Spasmophilia untreated may last indefinitely. 
Mild spasmophilia may last only a week or two. It is not 
dangerous to life unless severe general convulsions develop. 
Properly treated, it can usually be controlled readily in a few 
weeks at the most. 
8 



114 INFANT FEEDING (BOSTON METHODS) 

Treatment. — The treatment may be divided into two parts: 
the treatment of the attack and the subsequent treatment in 
order to prevent further attacks. 

Treatment of the Attack. — The treatment is the same as for an 
ordinary convulsion. Give the baby a large dose of castor oil 
to get the bowels cleaned out ; get him into a hot tub, and give 
him sodium bromid and chloral by rectum, or anesthetize with 
chloroform if you prefer. Sodium bromid and chloral can 
usually be given in large doses to children by rectum : 5 grains 
of chloral and 10 of sodium bromid is not too much to give to a 
child a year and a half old. It is best given in a little warm milk. 

I never like to give morphin to babies or children if there is 
any other drug that can be used, for some of them bear it very 
poorly. 

Subsequent Treatment. — If the baby is a bottle-fed baby, as 
it most surely will be, get breast milk for it, if possible. Many 
times the mere substitution of breast for bottle milk will relieve 
the condition without any other treatment. If breast milk 
cannot be obtained, feed the baby a milk as high in its calcium 
content as possible by using a milk to which precipitated casein 
has been added, as there is a good deal of calcium in precipitated 
casein. See that the baby has several free movements of the 
bowels a day, and be sure that it gets plenty of water between 
feedings, in order to keep the kidneys active. I believe this to 
be of very great importance — keep the kidneys active. 

Drugs. — A number of drugs have been used in treating spas- 
mophilia. Extract of parathyroid gland has been given, with 
very small success, and it is probable that this is of little or no 
value in the treatment of the infantile type of tetany, at any 
rate. 

The drugs which are of value are the salts of calcium and 
magnesium. Calcium lactate may be given in large doses — the 
dosage depends mostly on the results which are obtained with 
it: if good results do not follow its use, use more. Five grains 
every three hours is a safe dose to start with for a baby a year 
old : it may be increased if necessary. 

Calcium chlorid may be used in the same way and is said by 
some pediatricians who have had a great deal of experience with 
spasmophilia to be of more value than the lactate. 



RICKETS — SCURVY — SPASMOPHILIA 115 

Run the dosage of this up until it has some effect in diminish- 
ing the spasms or the child's stomach is upset. The great 
trouble with calcium chlorid is that it is very irritating to the 
stomach. 

Subcutaneous injections have been used by some pediatricians 
in the treatment of tetany, with considerable success. An 8 
percent sterile solution of magnesium sulphate is used, and 0.2 
gram of the salt is given for each kilogram of body weight of the 
baby, 15 to 20 c.c. being injected at a time. 

I merely mention this method of treatment as I have had no 
experience with it myself. 

The use of calcium salts in the treatment of spasmophilia is 
a very rational procedure: there is much clinical evidence to 
support it. It has also been shown experimentally that the 
intravenous injection of calcium will almost immediately con- 
trol spasms of tetany in dogs who have been given the condi- 
tion by extirpation of the parathyroids. Spasmophilia is a con- 
dition which I am sure you will see here if you are on the look- 
out for it, and with proper treatment good results can be ob- 
tained in dealing with it. 



CLINICS 

CASE I.— VOMITING FROM IRREGULAR FEEDING 

A breast-fed baby (male) one month old. 

Family History. — Two more healthy children, whom the 
mother nursed, and who did very well on her breast milk. Other- 
wise not remarkable. 

Past History. — Full-term normal delivery; birth weight un- 
known. Breast fed any time he cries ; no regularity of any sort 
in the feeding : sometimes the feeding intervals are half an hour 
apart; sometimes three hours. 

Present Complaint. — At birth the baby was deeply jaundiced 
(probably icterus neonatorum and of no significance). 

Since birth he has vomited after nearly every feeding, usually 
immediately after feeding. Sometimes he vomits a large amount, 
but generally not a great deal. There are no tough curds in 
the vomitus, and it is rather thick and creamy in consistence. 
Occasionally the vomiting is explosive in character, but this 
is by no means constant, occurring perhaps once a day. The 
baby has no colic, and seems well and healthy except for the 
vomiting. His movements are inclined to be constipated, but 
are of fair size : usually one or two a day. He nurses from ten 
to fifteen minutes at a time, and his mother keeps him reason- 
ably quiet after the nursing. 

Physical Examination. — The general condition of this baby is 
good. He lies quietly in his mother's lap, is bright and active, 
and does not seem to have lost much weight. His color is good. 
The physical examination is entirely negative ; there is no tumor 
to be felt in the abdomen, and no peristalsis to be seen. A 
stool examination would be of value, but the mother has brought 
no stool. 

Discussion. — A number of things may be considered in getting 
at the cause of this baby's vomiting. 

1. Pyloric Stenosis or Spasm. — It is very unlikely that he has 
pyloric spasm, as this is rare in breast-fed babies and is not 

116 



CLINICS 117 

likely to show itself so soon after birth. It is also unlikely that 
this baby has pyloric stenosis; his general condition is too good, 
and it is plain that a good deal of food is getting into his in- 
testine, because he is in a state of reasonably good nutrition 
and has large stools. 

The most probable cause of his vomiting is too much rich 
breast milk fed to him at irregular intervals. The mother has 
full breasts, with a good deal of milk, which she says seems 
to be very rich in quality. The baby is fed at any time, so his 
stomach is often distended, causing him to vomit. If the milk 
is high in fat, as it seems to be, this would also tend to cause him 
to vomit, and would also possibly account partly for his con- 
stipated stools. 

It is within the bounds of possibility, but is not at all prob- 
able, that this mother's milk may never be suitable for this 
baby, although it may be found upon chemical examination to 
be apparently perfectly normal in composition. You will 
occasionally see a case in which the breast milk seems to con- 
tain some toxic material that continually upsets the baby, but 
never assume that any case is of this type until you have ruled 
out all other causes of vomiting. I would treat this baby as 
follows : 

Have him fed regularly at three-hour intervals, and let him 
nurse only ten minutes at a time, and I believe it very probable 
that his vomiting will soon disappear under these conditions of 
feeding. If it does not improve after a thorough trial, it will 
be well to give him a couple of tablespoonfuls of lime-water 
before each breast feeding, and still if it does not improve, 
substitute a weak cow's milk modification for three of the breast 
feedings; if he vomits the weak artificial feedings, after thor- 
ough trial, as much as he does the breast feedings, it is likely 
that he has a mild pyloric stenosis. If he does not vomit the 
cow's milk feedings and continues to vomit the breast feedings, 
have the breast milk analyzed, and if it is of unfavorable com- 
position, try to modify it by the methods I suggested in the 
lecture on breast feeding. 

As a last and most remote possibility : if he still continues to 
vomit all the breast milk he takes and to keep down his bottle 
feedings, take him off the breast. I believe the prognosis to be 



118 INFANT FEEDING (BOSTON METHODS) 

perfectly good for this baby, and that his vomiting can be con- 
trolled simply by regulating the time and amount of his feedings. 



CASE II.— INDIGESTION FROM NERVOUS INFLUENCES 

A breast-fed baby (female) three weeks old. 

Family History. — The second child of healthy but very ner- 
vous and highly strung parents. The first child is two years old, 
very nervous, and subject to violent fits of temper. Otherwise 
well. 

Past History. — Born at term after a normal delivery. Birth 
weight, 8 pounds. Breast fed every two hours. 

Present Complaint. — The child has been very fretful and 
irritable for the past week, crying most of the time, and appar- 
ently having a good deal of colic, especially at night. She does 
not vomit, but has had a good deal of diarrhea, having usually 
eight to ten very loose stools a day, which look fairly normal 
except for the decreased consistence. She seems so uncom- 
fortable at night, and cries so much that the family get very 
little rest. She takes the breast well, usually nursing for about 
fifteen minutes. She weighs eight pounds two ounces; prac- 
tically no gain since birth. 

The state of the household is of considerable importance in 
this case; it is in a good deal of confusion. The nurse of the 
other child left about a week ago, as did also the cook, so things 
have not been running very smoothly and the mother is worried 
and nervous. 

Physical Examination. — Nothing abnormal is found on physi- 
cal examination of the baby, and she seems to be in a very fair 
state of nutrition. 

Treatment. — The thing of most importance to be done first 
in this case was to get the household straightened out, especi- 
ally to relieve the mother ol all care of the other child; and 
this was done. The grandmother, who was an extremely cap- 
able and sensible woman, came and took hold of things — took 
charge of the other child, and relieved the mother of all house- 
hold responsibility. This is extremely important: a nursing 
mother cannot nurse her baby satisfactorily if she has worries on 
her mind. 



CLINICS 119 

It seemed best in this particular case to give, only temporar- 
ily, however, a few bottle feedings to the baby, partly to rest 
the mother and partly to rest the baby's intestines, as it seemed 
likely that the breast milk was too rich. The mother was 
directed to feed the baby as follows: 

6.00 a. m.: Breast. 

8.30 a. m. : Breast. 
11.00 a.m.: Bottle. 

1.30 p. m.: Breast. 

4.00 p. m. : Bottle. 

6.30 p. m. : Breast. 

9.00 p. m. : Bottle. 

2.00 a. m. : Breast. 
These three bottle feedings were arranged in such a way that 
the mother had a chance to get outdoors in the morning and 
afternoon for exercise and a change of surroundings. The 
modification given was the following: 

Fat 1 percent Sugar 5 percent Protein 1.2 percent 

Lime-water }/$ milk and cream. 

Two ounces were given at each feeding. This was made up 
as follows: 

16 percent cream 3^ ounce 

Skimmed milk 23^ ounces 

Lime-water 1 ounce 

Water 4 ounces 

Milk-sugar 1 scant tablespoonful 

A sample of the mother's breast milk was taken at this time 
and sent away for analysis. The baby was seen one week later, 
and was found to be doing very well. The irritability and colic 
had improved a good deal, and the stools were fewer in number 
— six or seven a day instead of nine or ten, as before, but were 
still diminished in consistence. She took the bottle milk well, 
and was not upset by it. The report of the composition of the 
mother's milk came back as follows: 

Fat 3.8 percent Sugar 6.9 percent Protein 3 percent 

This was a reasonable composition, except for the very 
high protein percentage, which probably had something to do 



120 INFANT FEEDING (BOSTON METHODS) 

with upsetting the baby. The treatment at this visit was 
to increase the length of the feeding intervals to three hours, 
thus giving the baby seven feedings in the twenty-four hours — 
four breast and three bottle. The fat percentage in the 
bottle milk was raised to 2 and the sugar percentage to 6 
percent and the mother was instructed to eat meat or fish only 
once a day, in the hope of perhaps bringing down the protein 
percentage in her milk. 

One week later the baby was found to be doing very well; 
she slept nearly all night, had only three or four nearly normal 
stools a day, and had gained seven ounces. This time the 
treatment was to omit two of the bottle feedings, substituting 
breast feedings for them, thus giving the baby the following 
feeding schedule: 

6.00 a. m. : Breast. 

9.00 a. m. : Breast. 
12.00 M. : Breast. 

3.00 p.m.: Bottle. 

6.00 p.m.. Breast. 

9.00 p. m. : Breast. 
Night: Breast. 

The baby was seen twice afterward, and continued to do well 
under this regime, gaining from six to nine ounces each week. 

Discussion. — This is a common type of case. Fully as impor- 
tant as the feeding, and perhaps more so, is it to get the house- 
hold straightened out and relieve the mother of all worry, if 
possible. In this particular case it seemed best to give a few 
bottle feedings temporarily, and it worked out well, but in many 
cases this would not be advisable. Of course, it would be ab- 
solutely wrong to wean the baby in such a case as this, nor would 
it be advisable to take her entirely off the breast, even tem- 
porarily. 

Many babies of this type do much better on three-hour feed- 
ing intervals than on two- or two-and-one-half-hour intervals, 
and this baby did. In many cases no other treatment will be 
found necessary than to increase the length of the feeding in- 
terval. This baby was left permanently on one bottle feeding 
a day in order to give the mother a chance to get out and to 
get the baby used to taking the bottle, as in all probability this 



CLINICS 121 

particular woman will not be able to nurse her baby more than 
six or seven months. The strength and amount of this bottle 
feeding must, of course, be gradually raised as the baby gets 
older. 



CASE HI.— A BABY WITH OBSTINATE VOMITING CAUSED BY 

TAKING HIS MILK TOO QUICKLY— CONDENSED MILK 

BABIES 

H. W., male, seven months old, is brought on account of 
vomiting and malnutrition. 

Family History. — Unimportant. The second child of healthy 
parents. No tuberculosis in the family. No miscarriages. 

Past History. — Full term, normal delivery. Birth weight not 
known; weight at one month, 73^ pounds. 

He has always been fed on a bottle, with various modifications 
of condensed milk, up to two weeks ago, when the present feed- 
ing was started. He seemed to digest the condensed milk well, 
but was always hungry, and his mother thinks there has been 
no gain of weight for the last three months. Two weeks ago 
Dr. B. was called in because the baby was not gaining, and he 
put him on the following formula: 

Skimmed milk 24 ounces 

Lime-water 12 " 

Milk-sugar 2 " 

Barley water 12 " 

Six feedings of 8 ounces 
Fat 0.0 to 0.5 percent Sugar 6.25 percent Protein 1.6 percent 
Starch, about 0.4 percent 

Present Complaint. — The child has not seemed to do well on 
this feeding ; he will take only six ounces of it at a time, and he 
vomits after nearly every feeding, so that his mother judges 
that he retains only about half his food. The vomitus does 
not contain tough curds, nor do the stools. He is ravenously 
hungry, and takes his bottle of six ounces in about three min- 
utes. His stools are loose and green, with small white curds, 
sour smelling — about four to ten a day. It should be said that 
these stools had been this way for about a month before he was 
put on his present feeding, when he was taking the condensed 
milk modification. 



122 INFANT FEEDING (BOSTON METHODS) 

Physical Examination. — The striking thing about him is that 
he does not look sick. His particular characteristic is that he is 
small; he looks like a moderately well-nourished baby of three 
or four months, instead of one of seven months. He is happy 
and active, and at a casual glance you never would pick out this 
baby as one who vomits nearly half what he eats, and has a 
severe diarrhea, as his mother says he has. It is rather sur- 
prising that he looks in such good condition, but as you feel of 
him you see that his good condition is apparent rather than real; 
his skin is loose and his flesh is very flabby and soft. He has 
no teeth. 'There is nothing else noteworthy about the physical 
examination. He has no signs of rickets. 

Discussion. — This baby is one of the types of condensed milk 
babies. Condensed milk sometimes is of value to feed a baby 
on temporarily, but it should never be used as a permanent 
diet; if it is, bad results are sure to follow, the reason for this 
being that condensed milk is not a well-balanced food, consist- 
ing almost entirely of cane-sugar. Speaking very generally, 
three types of condensed milk babies are likely to be seen, as 
follows : 

1. A much undernourished baby, thin, and with rickets. 

2. A large, fat baby, who upon superficial examination may 
appear fairly healthy, but who is seen upon closer examination 
to be anemic and to have very flabby, soft flesh. 

3. A small baby, underdeveloped, of fair nutrition, but soft 
and flabby. It is to this last class that this particular baby 
belongs. 

What are the problems to consider in the case of this baby? 

1. To give him a food upon which he can gain weight and 
develop normally. 

2. To consider the cause of his diarrhea, and to stop it if we 
can. 

3. Why does he vomit, and what is the best way to stop it? 
His diarrhea is probably due to the fact that he has been fed 

on a very high sugar diet (condensed milk) over a long period of 
time. This sugar has fermented in the intestines, with the 
formation of volatile fatty acids, such as acetic, butyric, etc. 
These have irritated the intestine and given rise to an increased 
intestinal peristalsis and diarrhea. There is probably also a 



CLINICS 123 

secondary fermentation of what little fat there is present, and a 
much decreased absorption of all the food elements, due partly 
to increased peristalsis and partly to the abnormally acid con- 
dition in the intestine. The digestion is weak for all the food 
elements, especially for fat, as this baby has been fed on a food 
which contains very little fat, so his fat digestion probably re- 
mains undeveloped. The indications are for a food low in fat 
and low in sugar, the sugar used being dextri-maltose instead of 
lactose or sucrose, as it ferments less readily. He can also 
take a little starch, and can probably be fed on a fairly high per- 
centage of protein. We will discuss this feeding in more detail 
later. 

As to his vomiting : He is certainly not vomiting from an 
excess of fat, as he is on skimmed milk, and the mother seems 
to be skimming it carefully. It is also rather unreasonable to 
suppose that he is vomiting from protein indigestion, as the 
protein percentage in his milk is not high, there are no tough 
curds in his vomitus or in his stools, and the lime-water in the 
mixture equals 50 percent of the milk and cream, which would 
certainly prevent the formation of any tough curds in the stom- 
ach, and vomiting from this cause. 

There are two things that may cause vomiting in a baby, 
which are often overlooked, because they are so simple: 

1: A too freely running nipple, which makes him fill his stom- 
ach too quickly, and probably also gulp down a good deal of air 
with his milk. 

2. Shaking of the baby by his mother after he has eaten, to 
keep him quiet. A baby's stomach is placed much more ver- 
tically than an adult's is, and the esophagus is relatively shorter 
and wider, so that any movement when his stomach is full is 
very likely to make him vomit. A baby should always be laid 
quietly in his crib for at least half an hour after he has eaten. 

Now this baby, so his mother says, emptied his six-ounce 
bottle in three minutes; he should take about fifteen minutes. 
Let us look at the nipple. You see here is a nipple with three 
large holes in it, and when the bottle is inverted, the milk runs 
out in a steady stream, making a very fast nipple. This nipple 
is probably the principal cause of the baby's vomiting. Let us 
tell the mother to get a new nipple without any hole in it, to 



124 INFANT FEEDING (BOSTON METHODS) 

take a small needle, heat it red hot, and make a hole through 
the nipple with it through which the milk will slowly come drop 
by drop, and use this instead of the nipples she has been using. 
Also have her stop shaking the baby up after his bottle; have 
her keep him absolutely quiet for half an hour after each feeding. 
As to the details of feeding : six ounces at a feeding seem to be 
about all this baby will stand at the present time, so let us give 
him six ounces every three hours, seven feedings a day, at the 
following times: 

6.00 A. M. 

9.00 A. M. 
12.00 m. 

3.00 p. m. 

6.00 p. m. 

9.00 p. m. 

2.00 A. M. 
The formula that he is on at present is a reasonable formula 
for him except that we need to cut down the sugar percentage 
and substitute a malt-sugar (dextri-maltose) for the lactose he is 
now taking. So let us give him: 

Skimmed milk 24 ounces 

Lime-water 12 

Barley water 12 " 

Dextri-maltose 1 level teaspoonful 

giving a percentage of — 

Fat 0.0 to 0.5 percent Sugar 3.05 percent Protein 1.6 percent 
Starch 0.4 percent 

Of course, such a food as this is far below his caloric require- 
ments, and he will not gain weight on it, but we must first get 
his vomiting and his diarrhea straightened out before we can 
hope to make him gain. He should probably improve a good 
deal in a few days, and as he improves his milk can be gradually 
strengthened, but the fat and sugar will probably have to be 
kept fairly low for some time. I should think, in the course of 
two weeks, that we might expect to have this baby on some 
such formula as this: 

Fat 2.5 percent Sugar 5 percent Protein 2.4 percent Starch 0.75 percent 



CLINICS 125 

and that he would be taking seven ounces at a feeding instead 
of six. Do not increase the strength and the amount of a for- 
mula at the same time ; it is better usually first to increase the 
strength and then the amount. 

What points may be brought out from a study of this case? 

1. Condensed milk is an unsuitable food for a baby to take 
over any considerable period of time; it gets him into trouble 
sooner or later. Condensed milk is very likely to give a baby a 
sugar diarrhea and a weak digestion for fat. 

2. Such simple things as big holes in nipples and shaking up 
after feeding may cause severe vomiting; it is not always neces- 
sary to go into chemistry and science to explain vomiting. 

CASE IV.— CHRONIC SUGAR AND FAT INDIGESTION 

E. R., female, aged five months, is brought to the clinic on 
account of failure to gain. 

Family History. — The only child of healthy parents. No 
tuberculosis in the family. No miscarriages. 

Past History. — Born at full term after a normal delivery. 
The birth weight is said to have been ten pounds, but this is 
doubtful. Breast fed for five weeks, when the breast milk gave 
out. From this time up to a week ago she had been fed on 
various combinations of several different proprietary foods and 
condensed milks, all of which contained a very high percentage of 
carbohydrate. For a week she has been taking the following 
mixture : 

Skimmed milk 8 ounces 

Lime-water 3 " 

Milk-sugar 3 rounded tablespoons 

Water to make 32 ounces 

Four ounces every three hours. 

This gives a percentage composition of — 

Fat 0.0 to 0.5 percent Sugar 5.6 percent Protein 0.8 percent 

The chief trouble with the baby is failure to gain weight and 
looseness of the bowels. She takes her. milk well and never 
vomits, but loses weight steadily, and has daily at least four or 
five rather loose yellowish stools of about the consistence of 



126 INFANT FEEDING (BOSTON METHODS) 

scrambled eggs. These stools smell strongly acid and have 
many small, soft white curds scattered through them. 

Physical Examination. — A very small, poorly developed and 
nourished baby. The skin is loose and dry, showing evidence 
of a considerable loss of weight. Weight, seven pounds. The 
chest is very small; the abdomen is prominent, and apparently 
out of all proportion to the rest of the body. There is slight 
general glandular enlargement. The buttocks are red and irri- 
tated. There is nothing else of interest about the physical 
examination. 

Stool Examination. — The stool is soft, loose, yellow in color, 
with many small curds. The smell is strongly acid, as is the 
reaction to litmus. Microscopically there is a large excess of 
fat in the form of fatty acids and soap. This would seem not 
consistent with the skimmed milk diet, but can be explained 
by the fact that the mother is not skimming the milk 
properly. 

Discussion and Treatment. — This is one of the most com- 
mon types of indigestion seen in infants under a year old. It 
is a combination of fat and sugar indigestion. The baby has 
been fed always on a food high in carbohydrate, and chronic 
sugar indigestion has resulted. The exact mechanism of the 
fat indigestion is not well understood, but it is certain that in 
this type of case sugar indigestion does not represent the whole 
story by any means, and that fat indigestion, or failure of fat 
absorption, more properly speaking, plays fully as important 
a role as does the sugar indigestion. Which of the two is pri- 
mary it is hard to tell — probably the sugar. The stools that this 
baby has are very characteristic of the condition, and are so 
strongly acid, that they have excoriated the buttocks. The 
treatment is difficult — one of the most difficult problems in 
infant feeding. 

Principles of Treatment.— These babies always do best on a 
food low in fat and sugar and high in protein in an easily as- 
similable form. In most cases, but not in all, a malt-sugar 
preparation is tolerated better than milk-sugar. The principle 
of feeding is the same as for fermentative diarrhea: to change 
the reaction of the intestine from strongly acid to faintly acid, 
neutral, or faintly alkaline by feeding to the baby a high protein 



CLINICS 127 

and a low fat and sugar food, the end-products of which will be 
alkaline. 

If we feed a baby of this type from a milk laboratory, the 
problem is comparatively simple: we write a prescription for 
so much fat, sugar, and protein in the milk, and it is delivered 
at the door next morning all made up. In feeding cases of this 
type from a milk laboratory I nearly always use a mixture con- 
taining a low percentage of fat and malt-sugar and a high per- 
centage of protein in the form of precipitated casein. Some- 
times I use olive oil in place of the milk-fat; in these cases the 
whole mixture is run through the homogenizing machine, thus 
making a very easily digested preparation, as the protein is in 
the form of precipitated casein and cannot coagulate in the 
stomach, and the fat-globules have been broken up so finely by 
the homogenization that their digestion and absorption are very 
easy. If a milk laboratory is not available, the next best food 
upon which to feed these cases is Finkelstein's "Eiweiss" milk. 
Very good results are often obtained with this. 

Details of Treatment. — Finkelstein's "Eiweiss" milk, you 
remember, is made up as follows: Heat one quart of whole 
milk to 100° F. Add four tablespoons of essence of pepsin and 
stir. Let it stand at 100° F. until a curd has formed, and strain 
off the whey from the curd. Press the curd through a fine sieve 
three or four times. Add one pint of water to the curd and one 
pint of buttermilk to this mixture. This gives a food contain- 
ing— 

Fat 2.5 percent Sugar 1.5 percent Protein 3 percent 

So let us put this baby on "Eiweiss" milk, giving eight feed- 
ings of four ounces each to start with. Later the amount can 
be increased. It will be better, also, at first to have the mother 
make the curds from skimmed milk instead of whole milk, 
as this baby's fat tolerance is low, and she will probably do 
better on a food containing very little fat. Later we can raise 
the fat percentage. She will probably need to be kept on 
"Eiweiss" milk for several weeks. After several days, if her 
movements become better and tend more to the alkaline re- 
action, malt-sugar may be added to 3 or 4 percent. After four 
or five weeks the "Eiweiss" milk may be gradually discon- 



128 INFANT FEEDING (BOSTON METHODS) 

tinued and she can be put on a skimmed-milk and gravity cream 
modification, with a rather low fat and sugar and a higher pro- 
tein percentage. 

You will say that such a method of milk preparation is too 
complicated for many people to carry out. This is true; it is a 
rather complicated method, but with such a baby as this it is 
impossible to obtain satisfactory results with simple milk and 
water dilutions. Neglected babies of this type have practically 
no chance of surviving; properly treated, most of them do very 
well. 

CASE V.— THE FEEDING OF AN EIGHTEEN-MONTHS-OLD BABY 
WITH CHRONIC FERMENTATIVE DIARRHEA 

W. L., male, eighteen months, is brought on account of diar- 
rhea. 

Family History. — Not remarkable. The only child of healthy 
parents. No tuberculosis in the family. No miscarriages. 

Past History. — Full-term, normal delivery. Birth weight 
unknown. He was breast fed ten months and then was put on 
whole milk, cereals, bread, and potato. He has always been 
well, although not particularly rugged, until the onset of his 
present complaint four weeks ago. 

Present Complaint. — For nearly four weeks he has had diar- 
rhea — from seven to ten loose green stools, containing mucus, 
a day. These stools have contained a good many small white 
curds, but there has been at no time any blood present. He 
has had a little fever at night occasionally, — from 100.5° to 
101.5° F., — but has had a good appetite, not seeming particu- 
larly sick. He has never been weighed, but his mother thinks he 
has lost a good deal during the last four weeks. At present he is 
taking skimmed milk and barley water, equal parts, eight ounces, 
six times a day. In the last few days his stools have been a 
little better, but he still passes five or six a day; they are very 
loose, slightly green, and contain many fine white curds. 

Physical Examination. — As we look at this baby we can see 
that his general appearance indicates that he has lost a good deal 
of weight, but still that he is not yet in the "atrophic" stage. 
He is pale, with dark circles beneath his eyes; his flesh is very 
flabby and his skin loose. He has probably lost from four to 



CLINICS 129 

five pounds in the last few weeks. His abdomen is prominent 
and lax; his liver is felt about 4 cm. below the costal margin. 
There is nothing else of interest about the phj^sical examina- 
tion. He has no evidences of rickets. 

Discussion. — This child has probably had a fermentative 
diarrhea, due to carbohydrate fermentation, from which he is 
slowly recovering. The fact that he at no time had blood in his 
stools, that he did not seem particularly sick, and that he had 
very little temperature, would rule out infectious diarrhea. 
We know that his diarrhea is clue to fermentation of carbohy- 
drate because the stools are acid in reaction and green in color. 
He has never been fed a particularly high carbohydrate food, 
so we can assume that his trouble came in the beginning from 
milk probabfy infected with the Bacillus proteus, the colon 
bacillus, or one of the numerous other microorganisms that may 
cause fermentative diarrhea. He has been treated reasonably 
and well, and has improved somewhat, but not nearly so fast 
as he should have done. What is the reason for this? Let us 
inquire into the particulars of the milk he is taking and its mode 
of preparation. 

We find that the milk he is taking comes from a Jersey cow 
owned by his father; that it is skimmed after standing only two 
hours, and that it is not boiled. 

When we examine his stool microscopically we find that it 
consists almost entirety of soap, although it is supposed that he 
is being fed on a milk free from fat. This means that the milk 
is not being; properly skimmed, and as it is a rich milk from a 
Jersey cow, this child is probably getting at least 2 percent of 
fat in his diet, when he should have none. It is of great im- 
portance to keep the fat low in this case, and this is why he 
has not improved more rapidly. This is a very important 
point — you may think you are feeding a skimmed milk some- 
times, but are not at all, because the milk may be very rich 
milk to start with, and is not being skimmed properly. You 
will see a great many cases like this. Let us tell this mother 
not to skim the milk until it has stood six hours, and then to 
get all the cream off that she can. Of course, it is impossible 
to obtain an absolutely fat-free milk by hand skimming, but it is 
probable that the fat can be reduced to 0.5 percent or less. 



130 INFANT FEEDING (BOSTON METHODS) 

Also, we will tell her to boil the milk five minutes; this is im- 
portant. The weather is very hot at present, and milk spoils 
quickly in this climate if it is not boiled, and it is probable that 
contaminated milk was the cause of this child's trouble to begin 
with, so let us boil his milk ten minutes. If you feed a child 
for any length of time on boiled milk, it is best to give him 
orange-juice, to prevent the development of scurvy, but we 
shall not start giving orange-juice to this particular baby until 
his diarrhea has cleared up. Let us give him this modification : 

Skimmed milk 24 ounces 

Barley water 24 " 

Six feedings of eight ounces each. 

This mixture has the following composition: 

Fat 0.0 percent Sugar 2.25 percent Protein 1.6 percent 

Starch 0.75 percent 

This, of course, is a very weak milk for this baby, but we must 
feed him on a weak milk for a few days, as he is at present un- 
able to digest a stronger one. We shall see him again next week. 
Weight at present, 20 pounds. He probably will do well, but 
will gain weight slowly. 

July 5th. — He is taking his milk well and is having two or 
three small stools a day — slightly acid, yellowish, no excess of 
fat microscopically. Weight, 193^ pounds. It is safe to raise 
his feeding a little, so we can give him now 48 ounces of un- 
diluted skimmed milk, with the addition of four tablespoonfuls 
of dextri-maltose, giving a sugar percentage of 7.7, which is a 
fairly high sugar percentage to feed to a baby such as this; 
but he is in such good condition that he will probably stand it. 
If, after a day or two of this feeding, he has no trouble, we will 
tell his mother to give him four tablespoons of barley jelly a day. 
It is best to have his milk skimmed for a while longer. We 
give dextri-maltose because it is usually much more easily 
handled by babies of this sort than lactose is, and is not so easily 
fermented. You remember I told you in a previous lecture 
how to make barley jelly; four tablespoons of barley flour to a 
pint of water; cook one hour in a double boiler, add enough 
water to make up to a pint again, strain and salt. This is an 
extremely valuable preparation to feed babies on (over a year 



CLINICS 131 

old) who are convalescing from diarrhea, either infectious or 
fermentative, and I want to urge you to use it a great deal more 
than you do: it is not used half enough. In fermentative diar- 
rhea the digestion for fat is poor, as is that for sugar, but the 
digestion for starch in moderate amounts is usually good, be- 
cause it is broken down so slowty in the intestine that its end- 
products are present in small amounts and have little chance 
to ferment. Powdered zwieback is also valuable to use in 
such conditions. 

July 12th. — Weight, 193^ pounds. He is not doing well; 
he is very hungry, and has had a bad diarrhea for the last few 
days. When we examine the stools we see that they are of a 
greenish-brown color, slightly acid, without curds, and of a very 
mucilaginous consistence, with many small, jelly-like masses. 
When we examine them microscopically with Sudan III and 
acetic acid, we see that there is no excess of fat present, but 
when we add iodin, we see many small blue starch-granules. 
The appearance of this stool is absolutely characteristic of 
acute starch indigestion, so that is what is troubling this baby at 
present; he is either getting too much starch in his diet or is 
not digesting what he does get, at any rate. We had this baby 
on four tablespoonfuls of barley jelly a day, which certainly 
ought not to be too much for him, so let us ask the mother just 
how she makes the barley jelly and how much he takes of it. 
We find she makes it exactly according to the directions we gave 
her last week, but that she thought I said four tablespoonfuls 
with each feeding, instead of only four during the day, so the baby 
is getting 24 tablespoonfuls of barley jelly a day. No wonder 
he has starch indigestion. This illustrates the importance of 
writing down all orders for feeding cases. I should have done 
it for this one. Let us feed him as follows: 

Skimmed milk 48 ounces (six feedings 

of 8 ounces) 
Dextri-maltose 3 tablespoons 

for two days, and then if he does well, change the feeding to this: 

Whole milk 4 ounces 

Skimmed milk 44 " 

Dextri-maltose. 3 tablespoons 

Barley jelly 3 tablespoons a day 



132 INFANT FEEDING (BOSTON METHODS) 

This gives a percentage of: 

Fat 0.33 percent Sugar 6.9 percent Protein 3.2 percent 

July 19th. — He is doing very well, is hungry and gaining 
weight. Two stools a day — no excess of fat. Weight, 20 
pounds. Let us increase his feeding to : 

Whole milk 16 ounces 

Skimmed milk 32 " (six feedings of 

eight ounces) 

Dextri-maltose 2 tablespoons 

Barley jelly 3 tablespoons a day 

Zwieback 2 a day 

Orange- juice 2 tablespoons a day 

July 26th. — Doing well, but has not gained. Stools one or 
two a day — normal looking. He has not gained, because he is 
still on a diet far below his caloric requirements, and he has 
grown tired of barley jelly and has refused it at nearly every 
feeding. It is safe- to increase his diet a good deal this time, so 
let us give him: 

Whole* milk 24 ounces 

Skimmed milk 24 " 

Dextri-maltose 2 tablespoons (giving a per- 
centage of fat, 2; sugar, 
6.1; protein, 3.2) 

Farina 6 tablespoons a day 

Zwieback 4 a day 

Orange-juice 2 tablespoons a day 

Farina or Cream of Wheat is a most excellent food for small 
babies, and is probably the best cereal to give them after they 
have graduated from barley jelly. It is important to cook it 
very thoroughly; it should be cooked at least half a, day in a 
double boiler. It is better to give it without sugar if the child 
will take it this way. 

August 2d. — Weight, 21J/2 pounds — a gain of 1^ pounds in 
the last week. The child looks very much better and is going 
ahead fast. 

How shall we feed him now? We can consider him now as 
essentially a normal baby, and we can feed him as such, except 
that we must still keep rhe fat in his diet rather low, or it is very 
doubtful whether he would take full Jersey milk even now. 



CLINICS 133 

He needs more solid food. A baby of this age, on a normal 
diet, should not take over a quart of milk a day, for if he does 
he will not take enough solid food. So let us cut his daily milk 
allowance to 32 ounces and have it mixed as follows : 

Whole milk 16 ounces 

Skimmed milk 16 " (four feedings of eight 

ounces each) 
Dextri-maltose 1 tablespoon 

Fat 2 percent Sugar 5.3 percent Protein 3.2 percent 

For the rest of his diet, give him the regular infant diet list, 
which I detailed to you in a previous lecture. He should have 
five meals a day, about as follows: 

6 or 7 a. m. : 8 ounces milk 
8.30 a. m. : Cereal and 8 ounces milk 

Zwieback and apple-sauce 
11.30 a. m.: 8 ounces milk 

Zwieback 
1.30 p. m. : Soup or beef-juice 

Mashed potato or macaroni 

Mashed peas 

Egg 

Custard 
5.30 p. m. : 8 ounces milk 

Cereal 

Zwieback 

Stewed prunes or apple-sauce 

What are the lessons to be drawn from a study of this case? 

1. Treat fermentative diarrhea due to carbohydrate with a 
food relatively low in sugar and fat and high in protein. 

2. Be sure that the fat in the diet is actually low; that the 
mother is skimming the milk in the right way, and is doing it 
completely. Take into consideration whether or not the family 
has a Jersey cow. Many babies who are supposed to be on a 
practically fat-free milk may have stools full of fat and do 
poorly, simply because the milk is not being skimmed properly. 

3. Write down carefully all directions to the mother: do not 
trust to verbal directions. 

4. Raise the diet slowly, first adding a malt-sugar preparation 
and then starch (to babies over a year old). Then small amounts 
of fat. Write out the exact quantities of each article of diet 
the baby is to have. 



134 INFANT FEEDING (BOSTON METHODS) 

CASE VI.— FERMENTATIVE DIARRHEA IN A SMALL BABYj 

J. C, male, five weeks old, is brought on account of diarrhea. 

Family History. — Four other children well. No miscarriages. 
No tuberculosis in the family. 

Past History. — Born at full term after a normal delivery. 
Birth weight, 83^ pounds. Breast fed five days, when the 
mother had abscesses in both breasts, which made artificial 
feeding necessary. He was put on J^$ milk and % water, with 
milk-sugar added to about 6 percent, 2J^ ounces every two and 
one-half hours. He did very well on this formula until yester- 
day, when he began to have diarrhea. Yesterday he had seven 
movements; today he has already had six up to 3 p. m. The 
stools are loose and green, but contain no blood or pus. They 
smell strongly acid and are also strongly acid in reaction. 

Physical Examination. — A fairly well-nourished baby, mod- 
erately sick at the present time, with a temperature of 101° F. 
The physical examination is entirely negative: there is no 
cause for the diarrhea to be found outside of the digestive tract. 

Discussion and Treatment. — This is a typical case of fermen- 
tative diarrhea of the carbohydrate type. The onset, the 
general condition of the baby, and the loose, green, acid stools 
are quite characteristic. The condition, as I have said before, 
is due to an abnormal fermentation of sugar in the intestine. 
This sugar is broken down into various acids, such as acetic 
and butyric, which irritate the intestinal mucous membrane 
and cause a diarrhea. The condition may be brought about 
sometimes by too great an amount of sugar in the food, which is 
broken down by the bacteria normally present in the intestinal 
tract, or it may be caused by the introduction of harmful bac- 
teria from without, in unclean milk. In this particular case 
the condition is probably due to the latter cause, as this baby has 
been fed throughout on a reasonable sugar percentage. The 
general plan in treating these babies is first to empty the in- 
testinal tract, if the baby has not already had enough move- 
ments to do this, and then to give a food low in sugar and fat 
and high in protein. The decomposition products of protein 
are alkaline in reaction, and if such a food as this, with a low 
fat and sugar content and a high protein, is given, the reaction 



CLINICS 135 

of the intestinal contents will return to normal. If there is 
little sugar there, it cannot be fermented, and so no more acid 
can be formed. 

It will be best to purge this baby well, so let us give it two 
teaspoonfuls of castor oil, repeated in three hours. (If the 
diarrhea had existed for several days and the baby were having 
12 or 15 stools a day instead of the 6 or 7 he is having, we would 
give no cathartic.) Then give sterile water, 2 3/2 ounces every 
two and one-half hours for twenty-four hours, after which milk 
feeding may be started. Let us put this baby on the following 
formula: 

Skimmed milk 12 ounces 

Lime-water 6 " 

Water 6 " : 

2j/2 ounces every two and one-half hours; boil the mix- 

. ture five minutes. 

This gives a percentage composition of 
Fat 0.0 percent Sugar 2.5 percent Protein 1.6 percent 

The milk is boiled partly to sterilize it and partly to make the 
curd from the protein softer and smaller. As the movements 
improve, in the course of a day or two I would begin to substi- 
tute small amounts of whole milk for a portion of the skimmed 
milk, and would also add sugar up to 4 percent, in the form of 
dextri-maltose. 

As the baby improves the modification can be gradually 
strengthened, until, in the course of seven or eight days, if 
everything goes well, he should be taking: 

Fat 2 percent Sugar 5 percent Protein 1.6 percent 
23^ ounces every two and one-half hours. 

I should give no drugs of any sort other than castor oil to this 
baby. This is given because this particular baby needs a purge; 
its intestine has not been thoroughly emptied. Colonic irri- 
gations would probably do this baby no good. 

Eiweiss milk could be used in the treatment of this case, and 
it is likely that the bowels would clear up more quickly with the 
Eiweiss milk than they would on the mixture we prescribed, as 
there is less sugar and more protein in Eiweiss milk than there 



136 INFANT FEEDING (BOSTON METHODS) 

is in our mixture. This baby, however, has not a very severe 
diarrhea, and will probably do well on the simple dilution we 
have prescribed, so there is no need of giving a complicated 
formula, especially as this mother is in very moderate circum- 
stances, has four other children, and has a house to take care of, 
with no spare time on her hands to take up in mixing Eiweiss 
milk. 

CASE VH.— INFECTIOUS DIARRHEA 

R. G., male, nineteen months, is brought to the clinic on 
account of diarrhea. 

Family History. — Three more children well: none dead. No 
miscarriages. No tuberculosis in the family. 

Past History. — Full-term, normal delivery. Birth weight 
unknown. Breast fed for fifteen months, then put on undiluted 
cow's milk, rice, eggs, cereal, and bread. He has never been 
sick, and has done very well in every way up to the onset of his 
present complaint. 

Present Illness. — A week ago he began to have diarrhea, at 
first four or five then eight or nine loose brownish-green stools a 
day, containing a good deal of mucus. There was no blood in 
the stools at first, but for the past few days they have contained 
blood in streaks, intimately mixed with the mucus and fecal 
material. The number of the stools is increasing: yesterday 
he had 12, with a good deal of straining and tenesmus. Three 
days ago he had a temperature of 103° F. ; since then it has been 
between 99.5° and 100.5° F. He has been considerably pros- 
trated since the onset of his illness, is listless and apathetic, and 
has a very poor appetite. No nervous symptoms or vomiting. 

For five days he has been fed on albumin water, about six 
ounces every three hours, with ten drops of brandy added to 
each feeding. 

Physical Examination. — His general condition is only fair; 
he lies relaxed and limp, and takes very little interest in any- 
thing. His eyes are sunken, his skin is loose and dry, and his 
abdomen is considerably sunken. He seems to have lost a 
good deal of weight. 

There is nothing else of interest about the physical examina- 
tion. 



CLINICS 137 

Treatment. — There is no use in giving a purge to this baby; 
the time to purge him was at the onset of his illness, when he 
was having only a few stools a day and was in good general con- 
dition ; but at present he is having so many stools, and so much 
straining with them, that it would undoubtedly do him more 
harm than good to purge him now. 

There seems to be no reason for starving him either; he has 
been practically starved for a week, and let me say here a word 
or two about starvation in this condition. It is not good prac- 
tice to starve a baby too long; rarely should any baby with 
infectious diarrhea be starved over twenty-four to forty-eight 
hours. I know that we all used to starve our cases of infectious 
diarrhea, sometimes for long periods, but experience has shown 
that this is not the best method of treatment, and that these 
babies will do much better if they are fed a weak milk mixture 
almost from the very first, after a short period of starvation. 
I have seen a great many cases of infectious diarrhea fed on 
albumin water, and do not believe in it — for two reasons : First, 
because there is practically no nourishment in albumin water, 
and we do not wish to starve the baby; secondly, because al- 
bumin water consists entirely of protein (and water), and the 
dysentery bacillus, which is the cause of most cases of infectious 
diarrhea, attacks protein very readily, and forms toxic decom- 
position products from it. So the indications are, in treating 
most cases of infectious diarrhea, to feed a food high in carbo- 
hydrate and low in protein, as the dysentery bacillus does not 
readily thrive on carbohydrate food, and the decomposition 
products which it produces from carbohydrate are not particu- 
larly toxic. 

To return to our baby. A reasonable feeding on which to 
start this baby would be the following: 

Skimmed milk 14 ounces 

Barley water (1.5 percent) 14 " 

Lime-water 7 " 

Boiled water 7 " 

Lactose 6 level tablespoons 

Seven feedings of six ounces each. 

This gives the following percentages: 

Fat 0.0 percent Sugar 7 percent Protein 1 percent Starch 0.5 percent 



138 INFANT FEEDING (BOSTON METHODS) 

As you can see, this is a food low in fat and protein and high 
in sugar. It is always important to keep the fat low in feeding 
these babies with infectious diarrhea, as it is usually impossible 
for them to digest even small quantities of fat. This formula 
could soon be raised to the following: 

Skimmed milk 21 ounces 

Barley water 14 " 

Lime-water 7 " 

Lactose 6 level tablespoons 

The principles in the further dietetic treatment of this baby 
are these : 

1. Gradually raise the strength of his food until, as he is be- 
ginning to convalesce and is having fewer stools, he will be tak- 
ing undiluted skimmed milk with sugar added to 6 or 7 percent. 
Also, at this time, he can be given a little more starch in the 
form of barley jelly, farina, or powdered zwieback. 

2. The last thing to do is to raise the fat, and this should be 
done slowly, by substituting every few days an ounce or two of 
whole milk for an equivalent amount of skimmed milk. 

3. As he convalesces gradually add other articles of food to 
his diet, remembering that no baby of this age can thrive on 
milk alone. This baby's digestion for starch will probably be 
good, so that barley jelly, farina, powdered zwieback, mashed 
potato, macaroni, etc., are the articles of solid food that you will 
rely on mostly for his subsequent diet. As he progresses he can 
be given beef -juice and a small amount of finely chopped meat. 
If he shows any tendency to sugar fermentation, it will be best 
to substitute maltose for lactose. 

At the present time I would give this baby no drugs, except 
possibly a few small doses of paregoric to diminish the tenesmus, 
which has apparently troubled him a good deal in the last day 
or two. 

It is important to give him water between his feedings, and 
this I would do. Also, as this baby has lost a good deal of fluid 
and at the present time is pretty well dried out, I would give 
him about 200 c.c. of normal salt solution subcutaneously. I 
feel that this is very important in treating these babies, and it 
will often give surprisingly good results. I believe that in a good 



CLINICS 139 

many fatal cases of infectious diarrhea the loss of fluid from the 
body is one of the most important factors in causing death. It 
is best not to give the fluid under the breasts, as is usually done, 
but to give it in the loose tissue of the abdomen on either side 
of the umbilicus. A baby with infectious diarrhea has none too 
much strength; it is important to conserve as much of it as 
possible, and if a pint of water is suddenly placed on his chest 
and he has to raise it (sometimes a tenth or a fifteenth of his 
own weight) every time he breathes, it may tire him a good deal. 
At present I should give no colonic irrigations to this baby, 
but later on, if his stools do not clear up as well as they should, 
and they continue to show a good deal of pus and mucus, I 
would give him every day a high colonic irrigation with 3 percent 
silver nitrate solution. 

CASE Vin.— ACUTE RICKETS 

J. S., male, was seen March, 1917. Age, nine months. 

Complaint. — Poor appetite; failure to gain. 

Family History. — Not remarkable. 

Past History. — Full term; difficult high forceps delivery. 
Birth weight, seven pounds. Never breast fed. 

Feeding. — He has always been fed on " top-milk" mixtures, 
and these have contained a high percentage of fat — usually 
over 4 percent. For the last month he has been on the follow- 
ing feeding : 

Top (14 ounces of two quarts) 25 ounces 

Skimmed milk 13 " 

Dextri-maltose 6 level tablespoons 

Five feedings at four-hour intervals; from 63^ to 7 ounces at 
a feeding. With this he also gets about six teaspoonfuls of 
beef-juice a day. 

Present Illness. — He gained weight very satisfactorily up to 
four weeks ago. The mother has been plotting the weight 
curve in Dr. Holt's little book, and it has followed the theo- 
retical curve very closely up to this time. For four weeks his 
weight has remained stationary, however. His appetite is 
poor: sometimes he takes only three or four ounces at a feed- 
ing. He never vomits. He has one or two very large, pasty, 



140 INFANT FEEDING (BOSTON METHODS) 

light-colored stools a day. For the last few weeks he has been 
very fussy, sleeps poorly, cries a good deal, and sweats pro- 
fusely, especially about the head. At no time has he had any 
apparent fever. Weight, 17% pounds. 

Physical Examination. — Looking at this baby casually, with 
his clothes on, one would be inclined to consider him a fairly 
healthy baby, except for a certain pallor, and this is what his 
parents have considered him: an unusually strong and healthy 
baby. He is bright and active, and interested in his surround- 
ings. 

When his clothes are removed, however, it is easy to see that 
he is in poor condition. The essential points of the physical 
examination are these: 

General Condition. — Flabby and soft; his skin hangs loosely 
upon his flesh. 

Skin and mucous membranes: Pale. 

Head: Normal in shape; anterior fontanel and sutures 
widely open. No craniotabes. 

Throat: Large tonsils and a discharging nose, which means 
infected adenoids. He has no teeth. 

Lymph-nodes: Generally enlarged, especially those of the 
neck, some of which are as large as marbles. 

Chest: Small in comparison with the abdomen. A well- 
marked " rosary" is present, but no Harrison's grooves. 

Lungs: Normal. 

Heart: Normal. 

Abdomen: Large and flabby, with very thin, lax walls. Dias- 
tasis of recti muscles. The liver edge is felt about 3 cm., and 
the spleen easily 2 cm., below the costal margin. 

Extremities: Negative; no enlargement of the epiphyses; 
no tenderness; no spasm or paralysis. Knee-jerks normal. 

Discussion. — Of course, this baby has acute rickets. The 
anemia, flabbiness, delayed dentition, enlarged spleen, rosary, 
etc., make this diagnosis unmistakable. 

The question is, how did he get it and what can be done for 
him? 

As I said in the lectures, rickets is a complex condition, and 
may be due to a number of causes, either singly or combined. 
Poor hygienic surroundings have nothing to do with this baby's 



CLINICS 141 

condition, as his parents are very well to do and he has always 
had the best of everything. The cause of his trouble is to be 
looked for in his feeding : he has always been fed on a food very 
high in fat. The formula that he is taking now contains a 
little over 5 percent, which is altogether too much for him. 
This excess of fat has, however, not been enough to upset his 
digestion much, to make him vomit or to give him a diarrhea. 
The way in which it has done him harm is this : the fat of cow's 
milk is not easily absorbed, partly owing to the fact that the 
free volatile fatty acids of the fat combine with the calcium 
salts of the milk and form insoluble calcium soaps, which can- 
not be absorbed. Thus, on account of the large amount of fat 
in this baby's food, the calcium of the food, which should be 
absorbed, has been rendered unavailable, and on account of 
this long-continued loss of calcium he has developed rickets. 
Not all cases of rickets are caused in this way, but a great many 
are, at any rate. 

According to my way of thinking, the feeding of this baby has 
been entirely wrong from the start. I very rarely believe in 
four-hour feeding intervals for most babies under a year old. If 
they are fed in this way, it is necessary to feed them too con- 
centrated a food, and I have happened to see lately a number of 
babies who have come to grief fed by this method. 

There was no opportunity to analyze the stool of this baby, 
but I am sure that if an analysis had been possible, at least 40 
percent of the fat intake would have been found in the stool, a 
large part of it in the form of calcium soap. 

Treatment. — Feeding. — The feeding of this baby was changed 
to the following Walker-Gordon formula: 

Fat 3.00 percent 

Sugar (dextri-maltose) 8.00 " 

Protein 2.40 " 

Barley starch 0.75 " 

Sodium citrate 1 grain to the ounce of milk and cream. 

Seven to eight ounces every three hours; six feedings 
in twenty-four hours. 

(About the same percentages could be obtained in a 
home modification by using 36 ounces of whole milk, 
12 ounces of 3 percent barley water, dextri-maltose, 6 
level tablespoons, sodium citrate, half a teaspoonful.) 



142 INFANT FEEDING (BOSTON METHODS) 

The baby has not been seen since he was put on this formula, 
but I feel sure that he will do better on it than he did on the 
other. 

Ordinarily, beef -juice would not be given to a baby as young 
as this, but it has probably done him no harm, and it may as 
well be continued. Personally, I think that beef-juice is greatly 
overrated, and while I do use it, do not consider it at all a neces- 
sary part of a baby's diet. 

Drugs. — Iron is definitely indicated for the anemia, and sac- 
charated oxid of iron, 3 grains three times a day, was prescribed. 

The following prescription was also given: 

Phosphorated oil 20 minims 

Cod-liver oil 4 ounces 

One teaspoonful once a day; after a few days, twice a day. 

It is very doubtful whether cod-liver oil and phosphorus do 
much good in rickets, but they are worthy of a trial. Cod-liver 
oil in small amounts is assimilated more easily than cow's fat, 
so even if the baby has been taking too much fat, there is no 
contraindication for the small extra amount of fat that he will 
get in the oil. 

Fresh air and sunlight are of the utmost importance for this 
baby. He should be out-of-doors or on an open porch nearly 
all day on reasonably good days. It must be remembered, 
however, that he is anemic, and that for this reason he will not 
stand cold well, and should not be sent out on very cold days. 

Prognosis. — It will be possible to make him gain weight, to 
help his anemia and general condition, and, I hope, to arrest or 
to modify the rachitic process. Just how much this process 
can be arrested or modified, however, is a question, but it does 
not seem likely that this case will be a severe one, and it is prob- 
able that the baby will recover without any serious deformities. 

CASE IX.— MIXED BREAST AND BOTTLE FEEDING 

R. W., male, is first seen February 10, 1917. Age, eight 
weeks. 

Complaint. — Failure to gain. 

Family History. — The only child of healthy parents. No 
miscarriages, no exposure to tuberculosis. 



CLINICS 143 

Past History. — Born at full term, normal delivery. Birth 
weight, 1% pounds. Breast fed every two and one-half hours. 

Present Illness. — The baby is brought on account of failure 
to gain weight ; he has remained stationary at eight pounds for 
several weeks. It takes him half an hour to empty the breast, 
and then he is not satisfied. No vomiting. Movements one a 
day, small, rather hard, and constipated. The mother says she 
thinks she has very little breast milk. She is a young, highly 
intelligent, normal appearing woman, is on a reasonable diet, 
and is drinking about two quarts of fluid a day. 

Physical Examination. — A rather small, poorly nourished 
baby, who has apparently started on the road downhill. His 
flesh is flabby, and his skin is loose and pouchy, although he is 
not in an extremely emaciated condition.. Weight, eight pounds 
(weight of a normal baby of eight weeks should be about ten 
pounds). The rest of the physical examination is essentially 
negative. 

Discussion. — Although this case is by no means a difficult or 
a complicated one, I have included it because it represents a 
very important group. There are a great many women who 
can partially nurse their babies, but who have to be helped 
somewhat with the bottle. This woman is of this type: her 
milk is agreeing with the baby perfectly, although there is not 
quite enough of it. The point I want to emphasize particularly 
is this : never wean a baby simply because the mother has too little 
milk or because it is too weak. Even if she can give the baby only 
four or five ounces a day, let him have it. It may seem quite 
unnecessary to lay so much emphasis upon this, but I have 
seen dozens of babies taken off the breast entirely and put on 
various proprietary foods simply because the mother did not 
have enough milk for them. The thing to do in such cases is 
to help out the breast milk by supplementary feedings of the 
bottle. The bottle milk is usually given immediately after 
each nursing, although if the mother has only a very little breast 
milk, it will probably be necessary to have several feedings at 
which the bottle is given alone. There are relatively few 
women who can nurse their babies successfully for a whole year, 
and mixed feeding often has to be resorted to, usually with very 
good results. 



144 INFANT FEEDING (BOSTON METHODS) 

Treatment. — In this particular case the treatment was as 
follows: The mother was instructed to nurse the baby fifteen 
minutes every two and one-half hours — eight feedings in the 
twenty-four hours, and immediately after each nursing to give 
two ounces of a Walker-Gordon modification containing the 
following : 

Lactose 5 percent 
Fat 2 percent Protein 1.4 percent 

Maltose 1 percent 
Sodium citrate, 1 grain to each ounce of milk and 
cream in the mixture. 

The maltose was added to correct the constipation, which it 
did very effectually. 

If this particular formula had been prepared at home, it 
would have been made as follows: 

Gravity cream 2 ounces 

Skimmed milk 5 " 

Water 9 " 

Milk-sugar 1}4 level tablespoons 

Maltine malt soup 1 scant level tablespoon 

Sodium citrate 7 grains 

The baby did very well on this feeding, and started to gain 
immediately. On February 17th his weight was 8 pounds 10 
ounces, a gain of 10 ounces in one week, and his progress there- 
after was very satisfactory. 



CLINICAL LECTURES 

ON 

INFANT FEEDING 

Chicago Methods 

BY 

JESSE ROBERT GERSTLEY, M.D. 



TO 

DRS. I. A. ABT, JULIUS H. HESS, ERNEST LACKNER, AND 
JOSEPH BRENNEMANN 

THE MEN WHO FIRST STIMULATED ME TO DREAM OF A 
EUROPEAN EDUCATION, AND TO 

MY PARENTS 

WHO MADE THIS DREAM A REALITY 



PREFACE 

The following lectures are the result of many influences. 
Two years spent in the European clinics with Finkelstein and 
his able assistants, L. F. Meyer and Ivan Rosenstern, with 
Czerny and with Knoepfelmacher, gave the writer the founda- 
tion. It was upon the recommendation of Dr. Julius H. Hess, 
Professor of Pediatrics at the University of Illinois, that the 
writer went to North Carolina. The welcome cooperation of 
the State University and the State Board of Health was in- 
valuable in its effect. To the energy and interest of Dr. J. W. 
Long, organizer of the western sections, and chairman of the 
'splendid organization of men in Greensboro, the writer is par- 
ticularly indebted. He was a constant encouragement and a 
large factor in the success of the work. The warm hospitality 
and great personal kindness of Drs. Henry Long, of Statesville, 
Mitchell Summerell, of China Grove, F. Raymond Taylor, of 
High Point, R. E. Flippen, of Pilot Mountain, I. W. Faison, of 
Charlotte, and many other good friends in North Carolina, 
changed an exceedingly hard summer into a pleasant vacation. 
Before commencing his own course the writer had the pleasure 
of hearing several clinics of his friend, Dr. Lewis Webb Hill. 
This privilege aided the writer greatly in outlining his own work. 
Many subjects which Dr. Hill covered thoroughly, the writer 
omitted in order to avoid unnecessary repetition. 

Those of the readers who are familiar with Finkelstein, may 
find in the following pages some variations from his writings. 
These are due to unpublished views obtained in personal con- 
versation, and to others which the writer has introduced upon 
his own responsibility and from his own experience. 

In classifying the following pages as Chicago methods of 
feeding, the writer by no means wishes to imply that these are 
the methods of all Chicago pediatricians. However, he be- 
lieves himself justified in stating that the majority of Chicago 

149 



150 PREFACE 

men have been influenced to a decided extent by the schools of 
Finkelstein and Czerny. 

The clinics following the lectures are made up of the case 
records of the course. In his notes the writer at times neglected 
to record the names of the physicians bringing the patient or 
raising questions for discussion. He has attempted to fill these 
in from memory, and so may have made errors. He trusts that 
this liberty, taken in the interest of teaching, will be overlooked. 
The curves are elaborations of the crude blackboard sketches; 
the photographs are from our hospital wards, taken to help 
illustrate the discussions. 

The writer is indebted to Dr. Alexander Day, of Northwestern 
University Medical School, for his kind suggestions as to the 
charts, to Mrs. Edna Walsh for much help in the manuscript, 
and to the publishers for their many courtesies. 

Jesse Robert Gerstley 

Chicago, III., 
September, 1917. 



CLINICAL LECTURES ON INFANT FEEDING 
(CHICAGO METHODS) 



LECTURE I 
INTRODUCTION 

Gentlemen: In coming to discuss with you the subject of 
children's diseases, I have been confronted with a serious prob- 
lem. To cover thoroughly the entire field of pediatrics in thir- 
teen lectures is obviously impossible. To skim over it super- 
ficially would leave you only with false impressions, would be 
worse than useless, and would do more harm than good. In 
attempting to plan the course, I thought it might be wiser to 
devote most of our time to those subjects in which ignorance or 
lack of experience of the physician leads to greatest injury to the 
patient. Probably in no other field of medicine are graver mis- 
takes made than in that of infant feeding and nutrition. Lasting 
misfortunes are brought upon infants from sheer ignorance of some 
of the simplest rules of feeding and hygiene. Indeed, one almost 
might say that if we have mastered infant feeding, in addition 
to a little hygiene, there would be no sick babies. Don't take 
this statement too literally. But I make it boldly, and repeat 
it, to show how much emphasis I lay upon the subject. For 
this reason I intend devoting the major part of the course to 
these considerations. 

In the clinics following the lectures we probably shall see and 
discuss some of the more familiar conditions. 

In the lectures upon infant feeding and nutrition we shall fol- 
low rather closely the teachings and viewpoints developed by the 
Finkelstein clinic and its converts. I also shall take the liberty 
of including in these discussions points advanced by other clinics; 
may at times venture to criticize some of these views on the 

151 



152 INFANT FEEDING (CHICAGO METHODS) 

basis of my personal experience, and occasionally shall insert 
ideas of my own. Don't misunderstand me; we of the Middle 
West have absolutely no objection to the percentage system of 
feeding. It undoubtedly gives good results in the hands of 
men used to it; but we believe our methods simpler to use and 
simpler to teach than those more commonly employed in the 
United States. 



MILK 

When we seek a substitute for breast milk, there is one, and 
only one, to offer, and that is cow's milk. No greater injustice 
can be done to a child than by failure of the physician to recog- 
nize or know this truth. No matter what advertisements you 
read; no matter what claims are made for proprietary foods, 
absolutely no substitute has been found for cow's milk. In 
view of its importance, let us devote ourselves this morning to 
a rather careful study of it, considering its chemistry, bac- 
teriology, and physical qualities. 

After you realize the importance of cow's milk as a food 
all the more striking must be the statement of M. J. Rosenau, 
the eminent professor of preventive medicine at Harvard, from 
whose writings on milk I now rather extensively quote, that 
milk is responsible for more sickness and more deaths than all 
other foods combined. Gentlemen, just think what this state- 
ment means: The one food next to breast milk in quality is 
responsible for more deaths, not than any other food but than 
all other foods combined! And it is this food we must feed 
our babies. 

According to Rosenau, the reasons for this statement are 
four: 

1 Milk is an ideal culture-medium for bacteria. They grow 
very well in it. 

2. It is the most difficult of all foods to handle and to deliver. 

3. It is the most decomposable of all foods. 

4. It is the only standard article of diet obtained from animal 
sources used raw. When one stops to think how we cook meat, 
eggs, boil soups, and cook all animal foods, it is surprising that 
we still use milk in raw form. 



MILK 153 



COMPOSITION OF MILK 

Milk is composed of five elements of food — not three, as we 
were wont to consider, but five. These five are: protein, fat, 
carbohydrate, salts, and water. It is the salts and water that 
are so frequently overlooked in the feeding of children and in 
the treatment of nutritional disturbances, and which are of such 
importance. We shall hear more of them. 

Protein is the substance which, in connection with salts, gives 
structure to the tissues. Protein is composed, in a general way, 
of carbon, oxygen, hydrogen, and nitrogen. When we speak 
of nitrogen-containing foods, we mean protein in distinction to 
the fats and carbohydrates, which contain only carbon, oxygen, 
and hydrogen. Protein in the milk is not, as you may think, a 
specific element, but exists as two kinds, viz., casein; and al- 
bumins and globulins. 

Casein is the substance that forms thick curds when milk is 
coagulated. The curds in buttermilk are of casein, and it is 
this casein that is the most important form of protein as regards 
infant feeding. 

Albumins and globulins form a scum on top of the milk when 
it is boiled. We always have thought them unimportant as 
regards feeding. 

Fat exists in the milk as an emulsion of fat-droplets. As a 
food, it is of value in supplying some energy to the body, and 
also is stored up in the tissues. It is the most variable constitu- 
ent of the milk. The first milk of the nursing or of the milking 
is poorest in fat. The last is richest. Fat varies in the milk of 
different animals. Jerseys and Guernseys contain more than 
Holsteins, and, not infrequently, a baby who is vomiting can be 
cured by changing from the milk of a Guernsey to a Holstein. 

Carbohydrate in milk, commonly known as sugar of milk, and 
technically called lactose, is of value in supplying energy to the 
body. Like casein, lactose is found only in the mammary glands 
and nowhere else in nature. When bacteria attack it, it usually 
is changed to lactic acid, this being the acid that is formed in 
buttermilk; so buttermilk is simply milk in which the fat has 
been removed and the sugar changed to lactic acid. 

Salts in connection with casein furnish structure to the tissues, 



154 INFANT FEEDING (CHICAGO METHODS) 

and are vitally concerned in many of the nutritional disturb- 
ances. 

Water is perhaps the most important element in the body, 
being the universal solvent and constituting the greatest pro- 
portion of the body tissues. 

Besides these substances, a great variety of drugs and also 
some ferments may be found. From the standpoint of medicine 
these drugs are unimportant, because they rarely are of suffi- 
cient quantity to have any effect upon the child. An exception 
may be made, however, in the case of cows that have eaten 
poisonous weeds and grasses. 



ADULTERATION OF MILK 

If you, gentlemen, are interested in the study of children's 
diseases, you must know the ways in which milk is adulterated. 
The most common methods are skimming, watering, adding 
thickening agents and preservatives. To detect these adul- 
terations three means are at our disposal: 

1. Simple inspection. 

2. Bacteriological tests. 

3. Chemical tests. 

The method that I would recommend to you, one which is 
simple enough for any one, is that of inspection. Take the milk 
and look at it. Here, of course, you detect gross changes. Then 
filter through a piece of cotton placed in a little funnel. Heat- 
ing the milk makes it filter more easily. On this cotton you will 
find a stain varying from light brown to black, depending upon 
the amount of dirt. Looking at the cotton, one finds all sorts 
of things; Cow's hairs, manure and feces, scales of her skin, 
sand, straw, and food. It is well to remember that a wise milk- 
dealer sometimes filters the milk before selling it. 

The only chemical test that I would recommend is the Bab- 
cock. This requires a special apparatus, but those who are in- 
terested may at some time wish to have one. It is a quantitative 
test for fat. This is the technic: 

Take 17.5 c.c. of milk 

17.5 c.c. of sulphuric acid 
2.0 c.c. of amyl alcohol 



MILK 155 

I give you these in the metric system, for the tubes are gradu- 
ated that way. Remember that 30 c.c. equal 1 ounce; so we 
are using approximately one-half ounce each of these fluids. 
Centrifuge for four minutes; then add boiling water to bring 
the fat up into the graduated neck of the tube; centrifuge for 
two minutes and read. 

Other chemical and bacteriological methods require special 
training. 

DIFFERENCES BETWEEN COW'S MILK AND BREAST MILK 

A proper understanding of the difference in the composition 
of cow's milk and breast milk is absolutely essential to the feed- 
ing of infants and is the basis of all our methods of treatment. 
Let us give you this little table, which, though not absolutely 
accurate, still is sufficient for all practical purposes : 

Breast Milk Cow's Milk 

Protein 2.0 percent Protein 4.0 percent 

Fat 4.0 " Fat ■ 4.0 " 

Carbohydrate 6.0 " Carbohydrate 4.0 " 

Salts 0.2 " Salts 0.7 " 

Water 88.0 " Water ,....87.0 " 

An easy way of carrying these numbers in your head is this: 
breast milk being 2 4 6; cow's milk 4 4 4. Looking at this 
table, one gets the impression that the only difference between 
the two milks is in the amount of the different constituents. 
This, however, is not the case. 

Protein, as you remember, exists in the milk as two different 
elements: casein, and albumin and globulin. The proportion 
of these elements in the milk is entirely different. 

Protein of cow's milk contains: 

Casein 85+ percent 

Albumins and globulins 14+ " 



The protein in the breast milk consists of: 

Casein 61 + percent 

Albumins and globulins 38+ " 

To emphasize this all the more, look at the weights. If we 



156 INFANT FEEDING (CHICAGO METHODS) 

take 100 grams (a little over 3 ounces) of milk and weigh these 
different proteins, we find: 

Cow's Milk 

Casein 2.7 grams 

Albumins and globulins 0.2 gram 

Breast Milk 

Casein 0.8 gram 

Albumins and globulins 0.6 " 

Notice the preponderance of casein in cow's milk; and now, 
in addition to this, there is also a difference in the caseins of the 
mixtures themselves. Cow's-milk casein precipitates in firm, 
thick curds; breast-milk casein forms only the finest curds — 
sometimes none at all; and cow's-milk casein contains much 
more phosphorus than breast-milk casein. I emphasize these 
differences to show how futile it is to attempt to modify cow's 
milk so as to make its protein identical to that of breast milk. 

So far as we know at present, the composition of breast milk 
cannot definitely be influenced by diet other than that a poorly 
nourished woman, who secretes little milk, may perhaps be 
made to produce larger quantities by building up her nutrition. 

Fat. — Like the proteins of the tw T o mixtures, the fats are of 
somewhat different chemical composition. The fat of cow's 
milk contains more of the irritating lower fatty acids, of which 
butyric acid is an example, and there may even be some bio- 
logical variations. 

Carbohydrates, so far as we know, are alike. 

Salts. — Like the protein and the fats, there is great difference 
in the salt content of the two mixtures, not only in quantity, but 
in quality. Those in cow's milk are chiefly calcium and mag- 
nesium; those in breast milk, chiefly sodium and potassium. 
So you see we cannot, in any simple way, modify cow's milk so 
as to make its salt content identical to that of breast milk. 

BACTERIAL GROWTH IN MILK 

In offering an infant cow's milk, we frequently overlook the 
rapid growth of bacteria that may have taken place if the milk 
has not properly been cared for. Even if it has been kept at a 



MILK 157 

relatively low temperature, within two days bacteria will 
have multiplied by the millions, and at warmer temperatures 
the numbers found are absolutely incredible. Rosenau's 
statement certainly is impressive when he says that the milk 
we drink or we offer to an infant may contain more bacteria 
than are found in ordinary sewage. Just think of this! 
In feeding your babies milk mixtures you may be feeding more 
bacteria than are in ordinary sewage! These bacteria are 
usually of the type attacking the sugar and forming lactic acid, 
thus making sour milk, but they may be of any sort, and as 
they grow they may produce two important types of change: 

(1) If they attack carbohydrate they produce acid, this proc- 
ess being known as fermentation. In this fermentation usually 
lactic acid is produced, but under certain conditions other acids 
also result. 

(2) If, on the other hand, they attack the protein, they pro- 
duce alkaline products, this process being known as putrefaction. 

Gentlemen, I urge you to distinguish sharply between these 
two processes and remember that we shall hear of them time and 
time again. You cannot feed a normal baby, nor can you treat 
a baby sick with nutritional disturbance unless you have this 
clear-cut understanding of the changes that bacteria produce in 
milk. Let me repeat: When bacteria attack carbohydrate, the proc- 
ess is known as fermentation, and acids result. When bacteria 
attack protein, the process is called putrefaction, and alkalis result. 

From our standpoint of feeding, however, we must remember 
that the numbers of bacteria that are present in milk are by no 
means as important as the kind, and this brings us to the dis- 
cussion of the diseases which are known definitely to be carried 
by milk. 

MILK-BORNE DISEASES 

Studies have shown that tuberculosis, typhoid, diphtheria, 
scarlet fever, dysentery, and many other diseases have been 
traced to the milk supply. A study made in Boston some time 
ago shows what a factor milk can be in spreading disease, par- 
ticularly among children. To quote Rosenau: 

In 1907, in Boston, 72 cases of diphtheria and 717 cases of 
scarlet fever were transmitted by milk. In 1908, 400 cases of 



158 INFANT FEEDING (CHICAGO METHODS) 

typhoid were due to this cause. In 1910, over 842 cases of 
scarlet fever had this same origin; and in 1911, over 2065 cases 
of septic sore throat again were due to this cause. Gentlemen, 
see what a tremendous factor milk is in the distribution of dis- 
ease, and to what unnecessary danger we subject our babies in 
offering them this food. But don't forget that in spite of all 
this, cow's milk still is by far the best substitute for breast milk 
that we have. Cow's milk may become infected in different 
ways : it may be directly infected when obtained from the cow, 
but this is rare. About 2 percent of tuberculous cattle have 
involvement of the udder, and in these the milk may contain as 
many tubercle bacilli as does the sputum of tuberculous patients. 
Again, the cow with pulmonary tuberculosis coughs up the or- 
ganisms, swallows them, and they get distributed throughout 
the manure in the stable. During the milking they are whisked 
into the buckets, and these buckets of milk then being added 
to others, distribute tuberculosis throughout the community. 
Rosenau quotes a study of market milk in Chicago in 1910 
which showed that 10.5 percent of 144 specimens examined con- 
tained tubercle bacilli, as did 16 percent of all specimens 
of butter examined. In the same way other diseases are 
distributed, the most common one being typhoid. Wide- 
spread epidemics of this disease have been reported in all parts 
of the world, and have been traced absolutely and definitely to 
the milk supply. The organisms get into the milk, as a rule, not 
so much from a case of active typhoid as from a so-called typhoid 
carrier who works around the farm, viz., a man in perfect health 
who harbors typhoid organisms in his excretions. 

How are we going to avoid these dangers in feeding our babies? 
How are we going to offer babies cow's milk and, at the same 
time, not make ourselves liable to the terrible accusation that 
we have infected our babies with tuberculosis, typhoid, or dysen- 
tery? There are at present three methods at our disposal: 

a. Pasteurization. 

b. Demanding of certified milk. 

c. Boiling. 

I am going to speak very little of pasteurization, because if 
you are in no position to get certified milk, I doubt whether a 
State pasteurization law would be a great success. Indeed, 



MILK 159 

pasteurization may do more harm than good. Do you remem- 
ber that we spoke previously of the changes that bacteria cause 
in milk; that when they attack carbohydrate, lactic acid is 
formed? The greatest percentage of cases of spoiled milk result 
from fermentation and formation of lactic acid. This lactic 
acid in itself is not harmful, and by its presence not only may 
show that the milk has been improperly handled, but also may 
prevent dangerous organisms, such as typhoid or dysentery, 
from growing. If we should pasteurize the milk back on the 
farm, thus killing all the germs that produce lactic acid, and 
then, after having done this, we should permit a typhoid or a 
dysentery bacillus to get into that milk, this organism would 
have a perfectly clear field for growth. If, on the other hand, 
the milk were unpasteurized and it became spoiled, in the great 
majority of cases the lactic acid produced might prevent the 
growth of the more deadly organisms. So if you are not in a 
position to keep that milk absolutely free from contamination 
to the time of its delivery, I would not unreservedly recommend 
pasteurization. 

The term " certified milk" was introduced by Dr. Henry 
Coit, of Newark, N. J. According to our present conception, 
certified milk is simply milk of the highest quality, uniform in 
composition, obtained .from healthy cows under the supervision 
of a milk commission. I should advise you to become interested 
in this subject. What is necessary is for some of you to 
form a committee and enter into a contract with a reliable milk 
dealer. The dealer must allow frequent inspection of his dairy 
and frequent analyses of the milk. The cows must be pro- 
nounced free from tuberculosis by a reliable veterinarian, and 
must show a negative tuberculin test. They must be free from 
all communicable disease. They must be housed in clean, 
properly ventilated stables; the old wooden walls must give 
way to brick; the floors must be sloping to allow for flushing 
and to prevent the accumulation of waste and manure around 
the stalls. All persons coming in contact with the milk must 
be free from the germs of typhoid, tuberculosis, and diphtheria, 
and must observe scrupulous cleanliness. The milk must be 
drawn with the strictest care; the cows washed before milking; 
the tail tied to the leg, and the udders cleaned. The attendants, 



160 INFANT FEEDING (CHICAGO METHODS) 

dressed in white, must observe great cleanliness during the milk- 
ing process. The milk should be immediately cooled, placed in 
sterilized bottles, and kept at a temperature of not over 50° F. 
until delivered. It must be delivered within twenty-four hours 
after milking, and at that time may contain no more than 10,000 
bacteria per cubic centimeter. I should certainly advise you, 
gentlemen, to take some interest in establishing a certified milk 
dairy in this neighborhood. 

Until certified milk can be obtained, however, there is one 
method that remains for making perfectly safe the milk that 
you are feeding your babies, and that you may employ right 
now — this very day — boil your milk! In the olden times — a 
few years ago — when the science of bacteriology was being 
developed, it was thought necessary to boil and reboil the 
milk in order to kill any bacteria that it contained, and in 
these processes changes took place which made the milk a 
rather dangerous food. Children being fed this way frequently 
developed scurvy. Now we know, however, that if milk simply 
is brought to a boil and boiled gently for a minute or two, no 
such danger exists. We can speak with absolute assurance as to 
the harmlessness of feeding milk so treated. Just look for a 
moment at the European battle-fields. The men of France, 
Austria, and Germany seem to be pretty good fighting men, and 
every one of them who, when an infant was not fed on breast 
milk, was raised on boiled milk. In those countries raw milk 
is unknown. So you see that very good fighting men can be 
raised on boiled milk. If you wish to make yourself entirely 
safe, — to have your conscience perfectly free,— you may add a 
little orange-juice to the diet during the second month, and with 
this routine I can assure you that no case of scurvy ever will 
develop from this cause. 

In the discussion of boiled milk another question is raised 
which is of particular interest to me, for it was in Chicago that 
a very important problem along these lines was solved. The 
German pediatrician, Biedert, described curds appearing in the 
baby's stools — curds which were hard, white, and very much like 
a lima-bean in appearance. He said these curds were protein, 
and used them as evidence of the indigestibility of casein. This 
view later was corroborated by other observers. The new Ger- 



MILK 161 

man school, however, took a different view of the matter. Using 
more scientific methods, they fed children casein and found 
hardly any increase of nitrogen in the stools; and they argued 
that as feeding casein causes no increase in nitrogen in the stool, 
these curds could not be protein. American observers then be- 
came interested, and, if I remember correctly, Talbot, of Boston, 
was one of those insisting upon the fact that these curds did 
consist of casein. The Germans rather scorned this view, and 
claimed that the American methods were inaccurate. The 
Americans replied with more delicate experiments, using sero- 
logical methods, and again claimed that the curds were casein. 
The Germans replied that the methods now were too delicate, 
and that the Americans had identified the small amounts of 
protein that were present in the intestinal juices, but that the 
main structure of the curd was fat. The controversy waxed 
quite warm, and was finally settled by Joseph Brennemann, of 
Chicago, in one of the most important pieces of work that has 
been done in the field of pediatrics in America. 

Brennemann studied the cases coming to the dispensary of our 
medical college at home, Northwestern University Medical 
School. He found that the stools of many infants contained 
these curds. Careful study and observation showed that the 
curds varied from day to day — some days being present, some 
days absent. Careful questioning showed that at times the 
mothers boiled the milk, at times they didn't, and continua- 
tion of the study revealed the extremely interesting fact that on 
the days when milk was boiled the curds disappeared from the 
stools. When the milk was used raw, they returned. Here, 
then, was the simple solution of the great problem that had been 
vexing Europe and America. On the continent, where raw milk 
is unknown, the men never had even seen these casein curds, 
and, sure enough, what they had seen were curds of fat. In this 
country, with the previously invariable use of raw milk, we saw 
the true casein curd. So you see that the whole controversy was 
caused by our discussing and describing different things, and I 
can't help thinking that probably many of the great problems 
in pediatrics may be due to this same fundamental error — de- 
scribing and talking about different things. The formation of 
these curds is purely a physical process. It has nothing to do 
11 



162 INFANT FEEDING (CHICAGO METHODS) 

with digestion. They will form in the bottle as well as in the 
stomach, and are due not to digestive trouble, but simply to 
shaking of the milk after a ferment has been added. If we add 
a ferment to milk in a bottle and shake it violently, hard, tough 
curds form. The same holds true in the stomach. If, on the 
other hand, we introduce the milk into the small intestine by 
means of a Hess tube, thus saving it the mechanical shaking in 
the stomach, none of these abnormal curds form. The problem 
of this curd formation, then, is simply one of physics, and is not 
of particular interest to us from the standpoint of physiology. 

To conclude: remember, first, the fundamental differences 
between cow's milk and breast milk; remember that these 
differences are not only in the quantity of the individual ingre- 
dients, but also in quality, and that with no simple means at 
our disposal can we make cow's milk identical to breast milk. 
Remember that when cow's milk is not properly handled, bac- 
teria grow in it at a tremendous pace. In their growth they 
may cause one of two changes. If they attack the carbohy- 
drates, they produce acids, this process being known as fermen- 
tation; if they attack protein, they produce alkaline products, 
this process being known as putrefaction. I urge you, gentle- 
men, not to forget these two processes: fermentation and putre- 
faction. We shall hear them time and time again. 

Breast milk being high in sugar and low in protein favors 
fermentation. Cow's milk being high in protein and low in 
sugar favors putrefaction. 

Remember, however, that the quantity of bacteria is not so 
important as the quality, and that milk which may be swarming 
with lactic acid germs is not nearly so deadly as that which 
may contain smaller numbers of typhoid or tubercle or dysen- 
tery bacilli. If you wish to have a clear conscience in feed- 
ing your babies; if you wish to feel certain that you have not 
been responsible for a death from tuberculosis or typhoid or 
dysentery, you must see that the milk is pure. You have three 
methods at your disposal : The one I urge upon you is to boil 
the milk. In doing this you will positively work no injury to 
the child; you will change the protein so that no hard curds 
will appear in the stool, and you will protect the child from the 
deadly milk-borne diseases. 



LECTURE H 
DIGESTION OF MILK 

Gentlemen: In the last lecture we discussed the subject of 
milk. Today we take up "milk and the baby," considering 
carefully the changes that each causes in the other. We shall 
dwell upon the points in practical physiology that we absolutely 
must know in order to understand what is to come. Even if 
some of them seem a little abstruse or impractical, nevertheless 
I urge you to follow me, for you will find that I am telling you 
nothing that will not later be of importance. I am going to 
quote freely from Langstein and Meyer, which we should use as 
our text-book. 

The old idea of the digestion of protein was that in this process 
the protein simply became soluble. Now we know that protein 
digestion is a far more complicated process, the protein literally 
being torn to pieces by the ferments of the digestive tract. ' The 
individual fragments are called amino-acids. In the process of 
assimilation, these amino-acids are put together again and built 
into the structure of the baby's tissue. Protein digestion be- 
gins in the stomach and is completed in the intestine. 

In the intestine, protein performs an important function; 
viz., its digestion requires large quantities of alkaline intestinal 
juice, and in this way protein becomes associated with the for- 
mation of an alkaline reaction in the intestine. Practically all 
the protein is absorbed from the gastro-intestinal tract, par- 
ticularly when the milk is boiled. With raw milk large casein 
curds escape digestion, but with boiled milk very little nitrogen 
leaves the body by way of the stool. And this nitrogen does not 
necessarily have to come from the protein of the food, but may 
come also from the protein of the intestinal juices, of the in- 
testinal bacteria, and of the intestinal epithelium. Once past 
the digestive tract and into the body, this food has three im- 
portant duties: 

163 



164 INFANT FEEDING (CHICAGO METHODS) 

a. It will replace protein that has been lost from the body. 

b. It supplies substance to the tissues to satisfy growth. 

c. It can be used by the tissues for energy. 

It is interesting that the amount of protein retained in the 
body does not depend markedly upon the amount offered, the 
child retaining approximately the same amount of nitrogen 
whether fed on the low protein breast milk or the high protein 
cow's milk. When protein leaves the body, it is excreted prac- 
tically entirely through the urine. About 60 to 80 percent of 
it appears as urea and the remainder as ammonia and other 
waste-products. 

FAT 

Like protein, fat digestion begins in the stomach. There 
perhaps 25 percent of it is split up, the rest being digested by the 
ferments of the intestine. Unlike protein, however, some fat 
normally appears in the stool. Whether this fat has been taken 
into the body and then excreted into the large intestine, or 
whether it simply passes along the intestinal tract undigested, 
we do not know, but the fact remains that approximately 1 to 
10 percent of the fat taken by the baby will reappear in the 
stool. This fat is not necessarily in the same form as it was 
when the baby drank it. It may appear in three different ways, 
and these ways, gentlemen, I urge you to note, because we shall 
hear of them later. It may exist as : 

(1) Ordinary neutral fat. This is the simple fat that was 
in the milk. 

(2) Fat-soaps. I won't bother you with the chemistry of 
the formation of soaps, but in a crude general way remember 
that fat, when it joins alkalis, such as calcium and magnesium, 
forms a soap. This is not the absolutely correct chemical com- 
bination, but it will suffice. 

(3) Fatty acids. These, in contrast to soaps, are simply fat 
in combination with an acid. Again, this is not strictly chemi- 
cally correct, but it will do. 

So you see when the intestine is alkaline, soaps are formed, 
and when the intestine is acid, the soaps disappear and the fat 
becomes changed to a fatty acid. 

Most of the fat that passes the digestive tract is either burned 



DIGESTION OF MILK 165 

in the body or else is stored in the subcutaneous tissues and the 
liver. Fat, in contrast to protein, is not an absolute essential 
to the diet. Some babies thrive on buttermilk or on skimmed 
milk, with practically no fat. However, clinical observation 
would suggest that these children have a lessened degree of 
immunity to infection than those on higher fat diets. 



CARBOHYDRATES OR SUGARS 

In taking up the subject of carbohydrates, we consider perhaps 
the most interesting element of food. Carbohydrates exist in 
nature in three different forms: 

(1) Complex carbohydrates, of which starch is an example. 

(2) Less complex forms, known as disaccharids, of which 
lactose (milk-sugar), saccharose (cane-sugar), and maltose (malt- 
sugar) are examples. 

(3) Simple forms, of which glucose or grape-sugar is a good 
illustration. 

It is interesting that the body can use carbohydrate only in 
its simplest form, viz., that form which glucose represents. If 
we should inject a solution of lactose (milk-sugar) under the 
skin, this very same lactose would pass right through the body, 
would be absolutely untouched by the body tissues, and would 
be excreted in the urine as lactose. This holds true for prac- 
tically all the other more complicated sugars, with the one ex- 
ception of maltose. In some mysterious way the cells of the 
body seem to have the faculty of using maltose. So you see 
that the process of digestion of carbohydrate is simply a means 
by which more complicated sugars are split down to the simple 
ones — a means to adapt all forms of carbohydrate to the use of 
the body tissues. In this splitting process, we should remember 
the different stages through which a complex carbohydrate like 
starch passes. The first product is a substance called dextrin, 
which is very much like thoroughly browned flour. The next 
step is the formation of maltose, and the last step, the forma- 
tion of the simple sugars, such as glucose. That you may have 
a clearer picture, let me remind you that the simple sugar glu- 
cose is composed of C6H12O6; the disaccharids, meaning milk- 
sugar, malt-sugar, and cane-sugar, are composed roughly of two 



166 INFANT FEEDING (CHICAGO METHODS) 

of these simple sugars fastened together, and the complicated 
carbohydrates, such as starches, are composed of a great many 
of them bound together in different fashions. 

Just as with other food substances, most of the carbohydrate 
digestion goes on in the intestine. Here simple sugars are 
formed and practically all absorbed. In the normal baby one 
rarely finds any carbohydrate in the stool. One exception may 
be made in a child receiving a large amount of starch. If the 
starch is not thoroughly digested, it will appear in the stools. 

Having passed the intestinal mucous membrane, the carbo- 
hydrate enters the blood and is stored in the liver and muscles 
as glycogen. From these great storehouses the amount of sugar 
in the blood is kept at practically uniform composition, viz., 
0.1 percent. The end-products formed by burning are chiefly 
carbon dioxid and water. The carbohydrate is practically all 
burned, and never normally appears in the urine unless very 
large quantities are given. 

It is well to remember that a child has a very great tolerance 
for carbohydrate, apparently needing much more in proportion 
to his body-weight than does an adult. Just take this example, 
for instance: A baby weighing 10 pounds will drink approxi- 
mately 800 c.c. of breast milk — almost a quart. In this he 
gets 56 grams of lactose — almost 2 ounces. If we wish to feed 
an adult weighing 140 pounds the same amount of sugar in pro- 
portion to his weight, we would have to feed him 800 grams a 
day — almost 28 ounces. So you see what need the child has for 
sugar. Indeed, from the study of infant nutrition and disease 
we are learning much of the value of carbohydrate and the 
variety of functions it performs. 

a. First and foremost, sugars supply energy to the tissues. 
The baby moves and cries and performs all his daily work 
chiefly from the energy supplied by the carbohydrate. 

b. Interesting and not thoroughly explained is the fact that 
carbohydrate seems to save tissue protein. If we feed a certain 
amount of sugar, the baby seems to live on this and use up less 
of his body protein. 

c. Carbohydrate is related to the fat. If the body is not sup- 
plied with enough sugar, the fat of the food becomes poisonous 
and abnormal split products appear in the urine. When the 



DIGESTION OF MILK 



167 



carbohydrate is increased, these toxic products disappear. The 
old German clinician, Naunyn, described this in the striking 
sentence: "The fat burns in the fire of the carbohydrate." 
Just remember that sentence, gentlemen, " The fat burns in the 
fire of the carbohydrate," and you will have a striking picture of 
fat and carbohydrate metabolism. 

d. In contrast to fat, sugar cannot be replaced. Rosenstern, 
one of Finkelstein's assistants, in interesting experiments showed 
that if sugar is removed entirely from the diet, the baby will not 
thrive, and he proved conclusively that a baby to live must have 
a definite minimum. So in contrast to fat, sugar is absolutely 
essential to fife. 

e. We are begimiing to learn of an important relation that 
carbohydrates have to water in the body. This point is not 
absolutely established, some scientists saying that we have not as 
yet proved our point; but clinical evidence is very strong, and 
it is on the basis of this clinical evidence that I ask you to re- 
member that carbohydrates help the baby retain water. The 
following curve illustrates the observations which led us to these 
conclusions (Fig. 1): 



Da vs. 




1 


2 


3 


4 


5 


6 


6 
4 

2 
8 lbs, 


































A 












/ 


S ' 











"A" 



Fig. 1. — (From Langstein and Meyer.) 



If, at point "A," one should add a small amount, viz., two to 
three teaspoons, of a simple carbohydrate, to the bottle, fre- 
quently in one to two days the weight jumps up many ounces. 
How are we to explain this abrupt rise in the curve? A baby 
cannot gain several ounces from a few teaspoons of food. 
There is not enough protein, not enough fat, not enough carbo- 
hydrate in a few teaspoons to make several ounces. The logical 



168 



INFANT FEEDING (CHICAGO METHODS) 



conclusion is that this gain must be due to water. A child is 
like a sponge, absorbing water into his tissues and excreting 
it again very readily. Again, the removal of a small amount of 
sugar from this diet may lead to a sharp drop of five to six ounces. 
/. Sugars have an interesting relation to body temperature: 

(1) If the body is markedly cooled, glycogen seems to dis- 
appear from the muscles. 

(2) The following temperature curve will illustrate this from 
a clinical standpoint (Fig. 2) : 



99° 
98° 
97° 
96° 




































































































, 


























•r- 


• 
< 










































2 


p/o 










4 


o/ 


5 






































• 



Fig. 2. — (From Langstein and Meyer.) 

This child, with only 2 percent sugar in his diet, may have had 
a subnormal temperature for several days. If we increase the 
sugar to 4 percent, the temperature may rise to normal. 



MINERAL MATTER 

Gentlemen, the mineral matter in baby's food has long been 
overlooked. Indeed, even now the door has barely opened, but 
visions and dreams perhaps, begin to suggest the coming im- 
portance of mineral metabolism. One may almost say that 
physiologists are learning from the pediatricians. The baby is 
the simplest of all organisms to study. He is untouched by 
disease; his food is the simplest of all foods — can be analyzed 
and absolutely controlled; and to get correctly the total urine 
and daily stools in twenty-four hours is not a very difficult task. 
Hence the study of the baby has increased our knowledge de- 
cidedly in some of the fields of physiology. 

Of mineral matter, breast milk has 0.2 percent; cow's milk, 



DIGESTION OF MILK 169 

0.76 percent. You see that cow's milk has almost four times the 
salt content of breast milk. 

Strange that in our studies we have so long overlooked these 
differences. The splendid researches of Ludwig F. Meyer only 
relatively recently have been responsible for bringing them to 
our attention. Like other foods, salts are absorbed chiefly from 
the intestines. In the body they perform many functions, and 
then leave through the kidney and bowel. Through the kidneys 
most are excreted; through the intestines calcium, magnesium, 
and iron leave. Of course, we cannot say whether the calcium, 
magnesium, and iron found in the stool have been absorbed into 
the body and thrown out again, or whether they have simply 
passed unabsorbed along the child's digestive tract; but we do 
know that we find these salts in the stool. In passing, let me 
call your attention to the calcium: 

One Quart 

Breast Milk Cow's Milk 

Calcium 0.42 gram Calcium 1.72 grams 

This preponderance of calcium in cow's milk is an important 
factor in making the intestine alkaline. 

In the normal baby salts have a relation to protein, and for 
every definite amount of protein that the child absorbs a corre- 
sponding amount of salt is retained. This relation is far more 
definite in the baby on the breast than in the one on the bottle, 
and in disturbances of the latter often far more mineral is lost 
than is nitrogen. This improper relation of salt to protein in the 
artificially fed baby may feature in some of the disturbances. 

Gentlemen, I don't want to bother you too much with chem- 
istry, but let me give you one little glimpse into the possibilities 
of salt metabolism. Suppose we 

take a simple salt like calcium ^^ ^ 

chlorid; suppose that salt is in- 
troduced into the intestine. In 
the intestine it is split up into t 

calcium and chlorin. We just F - ~ 

have learned that chlorin is 

excreted chiefly in the urine; calcium, in the stool. We may 
picture this by the accompanying illustration (Fig. 3). 




170 



INFANT FEEDING (CHICAGO METHODS) 



Chlorin cannot leave the body alone, but must leave in com- 
bination with some other salt, usually sodium. The calcium 
makes other combinations in the intestines. Thus, feeding a 
simple substance like calcium chlorid forces sodium out of the 
body through the urine. This is a simple conception, but see 
what tremendous possibilities open to us ! Just picture to your- 
selves all the different salts of the baby's diet pursuing their 
individual courses through his body. See these possibilities! 
We barely are beginning to grasp them. How utterly in the 
dark are we as to the actual effects upon the child's organism 
of the complicated mixtures that we are wont to prescribe! We 



Ifc lb 
6 oz 

11 lb 

8 02 

10 lb 


98° 


. 




/ 


V 


>*s. . - — 


A 


*'%-.*• 


" '\~ V^-'* -' vv-v ^v 




\ 




VA 




\ 




\ 




\ 




^y\^ 



Fig. 4. — Drop in weight and temperature following salt withdrawal. 
(From Langstein and Meyer.) 

are barely at the beginning of understanding the true effects 
of our simple combinations, and you can see what enormous 
differences absolutely unknown to us must there be in the effects 
upon the child's body of the markedly different salt contents of 
breast milk and of cow's milk. 

Like protein, water, and carbohydrates, minerals are essential 
to life, and removal of them results in rapid death. The fasci- 
nating experiments of Jacques Loeb show that not only are 
minerals absolutely essential to life, but, if they are not present 
in the body in certain proportions, they may exert toxic in- 
fluences. The surgeons make use of these principles in their 
so-called balanced salt solutions. Like carbohydrate, salts 



DIGESTION OF MILK 171 

seem to have definite relation to body weight and temperature 
(Fig. 4). 

The removal of salts at A results in a drop of temperature and 
a marked loss of weight. The most important of all salts in 
causing these effects is sodium. Again, in chronic undernutri- 
tion, with deficiency of salt in the diet, the temperature may be 
consistently subnormal, and feeding a child in this stage about a 
dram of sodium chlorid may cause a marked rise in temperature, 
with fever. 

WATER METABOLISM 

The child's tissues are somewhat richer in water than the 
adult's. In a quart of breast milk a day, — a quart being 
equal to 1000 c.c, — he drinks 885 c.c. of water. Just see the 
percentage of water in baby's diet, — 885 parts to every 1000, — 
or, to put it differently: an adult uses approximately one-half 
ounce of water for every pound that his body weighs, while 
the child uses between two and three — about four times the 
quantity of the adult. Like the other food-stuffs, water is ab- 
sorbed chiefly from the small intestine. It is stored mainly in 
the muscles and normally leaves the body about 60 percent 
through the urine and about 40 percent through the lungs and 
skin. 

Like carbohydrate, salts have a definite relation to water 
(Fig. 5). 

If, at A, we add a teaspoon of salt to the diet, the baby's 
weight rises sharply. The inexperienced physician and the 
happy mother might exclaim: "At last we have found the 
proper diet! The child finally is gaining!" But, unfortunately, 
the excretion of this salt is accompanied by just such a precipi- 
tate loss as there was previously a gain. The weight comes 
down exactly to where it was before the salt was added, and 
now we rather ruefully learn that this great gain was not in 
true tissue substance, but was only in the water-content of the 
body. 

MILK IN THE GASTROINTESTINAL TRACT 

Gentlemen, we have considered the individual elements of 
the milk. We have studied them in the gastro-intestinal tract; 
we have followed them through the body; we have seen them 



172 



INFANT FEEDING (CHICAGO METHODS) 



in their excretion. Let us pause for a moment and look at the 
milk as a whole. 



8 lb 




12 ct 


h 


8,*a 


1 \ 


4 os 


1 \ 


7 lb 


I 1 


12 oz 


/ \ 


8 oz 


/ \ 


4 02 


^\ / \ 


6 lb 


^~^ — \_^ 



Fig. 5. — Gain in weight following addition of salt to diet. (From Lang- 
stein and Meyer.) 



In the stomach two important changes take place: the pro- 
tein, due to the rennet, coagulates, and the milk separates into 



DIGESTION OF MILK 173 

curd and whey. You remember that the curd consists of the 
casein, which, in its formation, ensnares some fat. In this 
process much of the calcium is dragged out of the whey and 
joined in chemical combination to the casein; so casein in con- 
nection with the base calcium becomes a powerful agent for 
making the intestine alkaline. The whey, you will remember, 
represents the water-soluble elements of the milk; i. e., the 
water, salts, sugar, and the albumins and globulins. This 
quickly leaves the stomach. The casein curd with the en- 
trapped fat may remain several hours to be thoroughly digested. 
This interesting little point in physiology explains the useless- 
ness of following the tables which older scientists with great 
pride and perseverance built for us, viz., feeding the child at 
definite ages, food in proportion to the capacity of his stomach. 
As a matter of fact, because the whey leaves the stomach so 
rapidly we often feed the baby more than one might imagine, 
and we may disregard entirely these older tables. You see we 
have at hand a means for hastening or retarding the emptying of 
the stomach. A mixture high in whey will leave the stomach 
rapidly ; a mixture high in casein and fat will leave slowly, and 
so, by altering our mixtures, we can greatly influence gastric 
motility. 

In the intestine the milk meets the various digestive fer- 
ments. The bile makes the fat soluble. Then the feipients of 
the pancreas and the intestinal glands, aided by the bile, seize 
all the fat, carbohydrate, and protein, and tear them down to 
their fundamental elements. These then leave the intestine. 



THE STOOLS 

The above in a very superficial way describes the digestion 
of the milk. Just what remains in the stool? In the stool 
are — 

a. Great quantities of bacteria. I put these bacteria first 
to impress you with their importance. Up to the present, 
in infant feeding, these bacteria have been almost overlooked 
although they may constitute 16 to 18 percent of the stool. 
You see the possibilities for bacterial action existing in the intes- 
tine. Normally, the organisms live only in the large intestine, 



174 INFANT FEEDING (CHICAGO METHODS) 

the upper intestine being sterile; but, under conditions of which 
we shall hear later, they leave their home, extend up to the small 
intestine, and nourish there. Why they normally remain only 
in the large intestine and do not thrive in the upper bowel is not 
absolutely known. Some men claim that the duodenum, either 
by its juices or by the properties of its cells, is able to exert a 
strong bactericidal influence. Kendall has suggested to me that, 
due to the rapid absorption of food-stuffs, bacteria may not 
thrive in the upper intestine, as no food remains for them. Prob- 
ably both factors are of importance. 

In the large intestine two different groups of bacteria exist: 
those living chiefly on protein, attacking this protein, and caus- 
ing putrefaction and alkali formation; those living chiefly on 
carbohydrate, attacking the sugars and causing fermentation 
and acid formation. 

Gentlemen, in the last lecture you heard of the importance 
of these two processes, fermentation and putrefaction. Just as 
readily as in the milk that stands at the doorstep, do these 
activities proceed in the child's intestinal tract; but here we 
have them perfectly under control. Feeding protein calls forth 
the putrefactive organisms; feeding carbohydrate calls those 
producing fermentation. Remember that putrefaction, with 
resulting alkaline change, slows down intestinal peristalsis and 
leads to an alkaline, foul-smelling stool. On the other hand, 
fermentation with resulting acid formation leads to increased 
peristalsis and to watery, greenish, sour-smelling diarrheal Stools. 
I urge you under no circumstances to forget that protein putre- 
fies; carbohydrate ferments. 

b. Besides bacteria, the stool consists of unabsorbed food- 
stuffs. 

(1) Protein, we learned, rarely appears normally in any appre- 
ciable quantity unless raw milk is given. 

(2) Fat is concerned somewhat in the actual structure of the 
stool. Feeding skimmed milk may result in thin bowel move- 
ments with mucus and small amounts of solid material; increas- 
ing the fat in the diet may give rise to a formed stool. It is the 
fat in the form of soaps which has most influence on stool 
structure. 

(3) Like protein, little carbohydrate is found normally except 



DIGESTION OF MILK 175 

in those cases where much starch is fed, this starch passing down 
the intestinal tract undigested. 

(4) The salts are of great importance. Calcium, for instance, 
by its insolubility in water, gives bowel movements of dry, 
alkaline nature. 

c. Besides bacteria and food substances, there are secondary 
products. Protein, as you remember, calls forth alkaline intes- 
tinal juice rich in albumin. Secondly, any protein that remains 
in the intestine unabsorbed will be attacked by the putrefactive 
bacteria, with resulting alkaline products. In the same way any 
unabsorbed carbohydrate will ferment into acid products. The 
amount of fermentation of this carbohydrate we can influence 
markedly by the nature of carbohydrate we use. Bacteria 
do not attack readily the complicated carbohydrates, such as 
starches and dextrins. When we feed starch or dextrin to a 
baby, this carbohydrate is changed by the digestive processes 
slowly to the simpler sugars, and these simpler sugars, as they 
are formed in small amounts, are absorbed through the upper 
intestine before the bacteria attack them. Thus complex carbo- 
hydrates, such as starch and dextrin, are normally rather con- 
stipating. The lower carbohydrates, such as milk-sugar and 
glucose, are readily attacked. When a child receives a large 
quantity of one of the latter some of the sugar may reach the 
region where intestinal bacteria are nourishing, and fermenta- 
tion, acid formation, and diarrhea result. Clinical observation 
suggests that the fermentation of these sugars is influenced by 
different factors: 

(a) Feeding the baby whey of cow's milk seems to increase 
the degree of ferment ability of the sugar. 

(b) An increased amount of protein with its putrefying alka- 
line-forming properties makes the sugar less fermentable. 

(c) The condition of the intestine is of great importance : 

(1) A perfectly healthy, intact mucous membrane will be able 
to keep bacterial growth under control and prevent a marked 
degree of fermentation. 

(2) A diseased intestine may not be able to combat a fermen- 
tation induced by high sugar feeding. 

You see, gentlemen, why I am dwelling upon these subjects. 
The condition of the baby's stool depends absolutely upon you. 



176 INFANT FEEDING (CHICAGO METHODS) 

You have at your disposal the means of making the stool alka- 
line, constipated, and hard, or acid, diarrheal, and watery. 
There is no mystery about the process; the explanation is 
simple; the means are at hand. Feeding a baby high protein, 
by inducing putrefactive change, by calling forth large amounts 
of alkaline intestinal juices, by bringing down large amounts 
of the base, calcium,* in connection with the casein, produces 
constipated, hard, soapy stools. Feeding large amounts of 
sugar, by inducing fermentation, with the resulting formation of 
various irritating acids, leads to diarrheal acid stools. Don't 
forget these important factors. 

Just one word about the energy of foods. 



ENERGY OF FOODS 

In the science of physics the term "calorie" is used. This is 
purely scientific, and means the amount of heat or energy re- 
quired to raise 1 gram or 1 kilogram of water one degree (30 
grams are an ounce). The older physicists investigated the 
energy content of various food-stuffs, and in their investiga- 
tions learned — 

1 ounce of protein represents about 120 calories. 

1 ounce of carbohydrate represents approximately 120 calories. 

1 ounce of fat represents approximately 270 calories. 

This is pure physics. It was due to the investigations of the 
children's specialist, Heubner, in connection with the physiol- 
ogist, Rubner, that these physical studies were applied to infant 
feeding. They showed that a normal baby, to thrive and gain, 
requires for the first six months approximately 45 calories for 
every pound of his body weight. For example, a baby weighing 
six pounds requires about 270 calories. From these studies has 

* Since delivering these lectures the writer has read the fascinating work 
of C. H. Clowes, Jour, of Phys. Chem., 1916, xx, 407, in regard to emul- 
sions. He has shown that the addition of salts of calcium to a mixture of 
oil in water, as, for example, cream, will promote the change of this mixture 
to an entirely different type, namely, an emulsion of water in oil, as butter. 
The author does not know if these studies have as yet been applied to nutri- 
tional disturbances. This effect of calcium salts may possibly be equally 
important, as regards causing constipation, as the effect of calcium as an 
alkali. 



ENERGY OF FOODS 177 

developed the caloric system of feeding first advocated by Heub- 
ner and later adopted by many pediatricians. We shall speak 
of it again. 

In conclusion, what points of this lengthy discourse are going 
to be of value to you in the feeding and treatment of nutritional 
disease? Remember, first and foremost, the great differences 
in putrefaction and fermentation; that any protein remaining 
unabsorbed leads to putrefaction and alkali formation, with 
resulting hard, constipated stools; that any carbohydrate re- 
maining unabsorbed in the intestinal tract leads to fermentation 
and acid formation, with diarrhea and watery stools. Remember, 
fermentation of the carbohydrate is greatly increased by the 
whey elements of cow's milk and by any diseased or weakened 
condition of the child's intestine. Normally, due to their gradual 
digestion, starch and dextrin ferment less readily than simple 
sugars. Remember, in a general way, the stool content, and 
that fat in the form of alkaline soaps gives structure to the stool. 
This is the fat in combination chiefly with calcium and mag- 
nesium. Remember that in the stools normally no carbohydrate 
is present, and that when milk is boiled, no undigested protein 
is found, thus disproving in a rather general way the previously 
held idea of indigestibility of cow's milk casein. Remember 
the functions of the different elements of the food. Protein 
and salts make up the tissues of the body. Remember what we 
said about carbohydrate, and that carbohydrate and salts seem 
to be important factors in pulling water into and out of the 
baby's tissues. 



LECTURE HI 

MODERN CONCEPTION OF DISTURBANCES OF 
NUTRITION 

Gentlemen, in the last two lectures we concerned ourselves 
with the subject of milk and with the subject of milk and the 
baby. Today let us start the most fascinating of all studies, 
the study of the baby. We wish to consider that great, bewilder- 
ing group of ailing, non-thriving, sick children, some with diar- 
rhea, some with constipation, described by the various terms 
atrophy, marasmus, malnutrition, inanition, indigestion, gastro- 
enteritis, ileocolitis, cholera infantum, and dysentery. You 
probably are conversant with the methods and teachings of 
the eastern schools. My purpose is now to give you the view- 
point of the middle West. In a general way we follow the 
European ideas. Wishing information from the very source, 
our younger men have sought foreign clinics, and it is informa- 
tion thus obtained which I wish to convey to you. After you 
have thoroughly mastered our methods you will be in a posi- 
tion to survey comprehensively the entire field and to make an 
intelligent decision for yourselves. 

A little review of history will be of great aid in understanding 
the modern developments. Let us return for a moment to the 
autopsy room in Vienna some twenty or thirty years ago. 
Vienna, as you know, is almost the home of pathology. Post- 
mortem examination is conducted with the same rigid care and 
exactness as is clinical investigation. Every patient who dies 
in the Vienna hospital must come to postmortem. It is natural 
that with such facilities, the whole Vienna teaching should 
follow pathological-anatomical lines. Even the clinicians made 
pathology the foundation of their diagnoses, and it was only 
logical to attempt to divide this great group of sick children 
into classes according to pathological findings. In Vienna one 
might say the conception was as follows: 

178 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 179 

The well baby was in a The sick baby might be 

group exclusively by him- affected with — 
self. 

a. Dyspepsia. 

b. Entero-catarrh. 

c. Cholera infantum. 

d. Follicular enteritis, etc. 

This was the consensus of opinion of the great Viennese pedia- 
tricians and pathologists. To them a well baby was a child to 
be neglected, not to. be considered by medical men. The well 
baby might play in his nursery; be of no interest until he as- 
sumed one of the types of disease. These types were described 
as local pathological-anatomical changes in the gastro-intestinal 
tract. In other words, if the baby vomited, he had gastritis. 
If he vomited and had a slight diarrhea, he had a gastro-enteritis. 
If he had a diarrhea with bloody stools, he had ileocolitis or 
possibly follicular enteritis. 

You see, then, that such a viewpoint made a sharp distinction 
between the well baby and the sick baby. The well baby was 
uninteresting, but the sick baby, by showing local changes in 
his gastro-intestinal tract, became very attractive and an object 
of much study. When it came to putting this classification 
into clinical practice, however, great difficulties arose, and 
when these clinical pathological diagnoses had been established, 
autopsy frequently failed to confirm them. Clinical pictures 
often changed. What one day was diagnosed entero-catarrh 
became the following day cholera infantum. Not even in sharp 
pictures, such as follicular enteritis, could the ulcerated intes- 
tine always be demonstrated. And in many cases showing the 
severest clinical symptomatology, as, for instance, cholera in- 
fantum, postmortem examination not rarely showed absolutely 
no change in the digestive tract other than perhaps a slight 
reddening of the mucous membrane. 

Slowly the pathologists became discouraged. Gradually 
they lost their interest in seeking pathological foundations, and 
now, if one goes to Vienna and stands in the great autopsy room, 
the lack of interest shown in the postmortem examination of 
infants is impressive. While great groups of men crowd around 
the tables seeking knowledge from the carefully, accurately con- 



180 INFANT FEEDING (CHICAGO METHODS) 

ducted autopsies of adults, dead infants are often absolutely 
neglected — not even examined. When one asks the busy pro- 
fessor why such and such a child is not autopsied, the answer 
is a shrug of the shoulders and " What's the use? We never find 
anything." This mute evidence from the anatomy room of 
Vienna speaks for the utter failure of pathology to provide a 
classification for these disturbances. 

The next attempt was made by the great Vienna pediatrician, 
Escherich. Not satisfied with pathology, he and his assistants 
sought etiological factors in pathogenic bacteria. Numerous and 
valuable researches were conducted, but in vain, for no specific 
microorganisms seemed to produce these clinical entities. When 
I say "He failed," gentlemen, I do not mean that he failed. 
His service was of tremendous importance, because negative 
evidence is as valuable as positive, and we could proceed only 
after having learned that our classification could not be founded 
upon bacteriology. 

The next step was taken by that almost romantic figure in 
pediatrics, Adalbert Czerny, the brilliant Austrian clinician 
who occupied the chair of children's diseases at Breslau. His 
great mentality, aided by keen clinical observation, has given 
the pediatricians of the world the most novel and most useful 
conception we have yet received. We must forever be indebted 
to him for introducing the new term, " disturbance of nutrition." 
In employing this term we already have a premonition of 
changes that will affect our therapy. This term implies that 
the child as a whole is affected, rather than exclusively his gas- 
trointestinal tract. Even though the trouble originates in the 
digestive organs, even though symptoms may entirely be those 
from stomach and intestine, still every organ in the body is af- 
fected. What a thought is this, gentlemen, to guide us in our 
therapy ! If the child as a whole is affected, we must admit that 
changes take place in his bones, in his muscles, in his skin, in his 
complete organism; and already our keen interest in the stool 
must wane. The stool becomes no longer our sole guide to 
therapy but merely one of many symptoms. 

Czerny was one of the first to doubt the indigestibility of 
cow's-milk casein. With the doctrine, "Protein can do no 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 181 

harm/' the very antithesis of former teaching, his skeptical brain 
cast the pediatrics world into furor 

Realizing the failures of pathology and bacteriology as aids in 
classification, he directed his studies from the viewpoint of 
etiology and gave us the famous Czerny classification. The 
grouping of " disturbances of nutrition" is according to etiology. 

1. Disturbances on the basis of infection. These may be of 
two types: 

(a) Direct bacterial infection of the child. 
(6) Milk or food spoiled by bacterial action. 

2. Disturbances on the basis of constitution. 

3. Disturbances on the basis of food. Of these, Czerny de- 
scribed two clean-cut clinical entities: 

(a) The condition which he called "milk injury," namely, a 
rather pasty, flabby child, not very sick, but not thriving, and 
very constipated. Czerny thought the etiology of this condi- 
tion to be high fat feeding; and so, though he gave the name 
"milk injury," he really meant " fat injury." 

(6) The condition he called " starch injury," a little ema- 
ciated, weak, undernourished baby, who has received an exclu- 
sively one-sided starch diet. 

Czerny's immeasurable contribution in this classification was 
the introduction of food factors, in the causation of a clinical 
picture. For the very first time we hear and think of a sharply 
defined, clearly described disease being due to nothing other 
than the food we offer the baby — perfectly good wholesome food, 
but mixed in improper proportions. What a tremendous differ- 
ence in our viewpoint results as regards our conception of the 
well baby! What Czerny has done is to impress upon us that 
the well baby is not necessarily well, but by a little one-sided 
feeding can be brought right over into the group which we had 
reserved entirely for the sick. Like this (Fig. 6) : 

1?ell Baby ^^ Sick Baby 

From Constitution. 
Prom Infection. 

From Food* 

Fig. 6. 



182 INFANT FEEDING (CHICAGO METHODS) 

In this study Czerny limited to two the clinical types which 
improper feeding could produce, namely: the pasty, consti- 
pated child resulted from fat, and the emaciated, undernour- 
ished one from exclusive starch. The diarrheal diseases he be- 
lieved due either to definite intestinal infection or to milk spoiled 
by bacterial action. 

Contemporaneous with Czerny, Finkelstein in Berlin was 
making remarkable clinical studies. Perfectly independently 
these two men worked, Czerny seeking the causes of disease 
and Finkelstein describing clinical pictures. Not by theorizing, 
not by hypothesis, but by careful observation at the bedside, 
sitting with his little patients by the hour, studying them with 
the care of a scientist in his laboratory, did Finkelstein arrive 
at conclusions which threw the already perturbed scientific 
world into chaos. The opportunities for clinical investigation 
in Berlin are enormous. Many great institutions care for the 
large number of illegitimate children that exist in that city. 
Finkelstein' s alone has over 300 beds for infants under two years 
of age. Studying and observing such infants are, of course, 
much simpler than in private practice, or even in ordinary 
hospital work. Many great men are in charge of these institu- 
tions, many have had the same opportunity as Finkelstein; 
but none had the great clinical insight and judgment to ac- 
complish what he has. 

His studies were of a purely clinical nature. He saw that 
some children had diarrheas ; some had constipation; some had 
fever, some subnormal temperature. In some the pulse was 
markedly accelerated; in others it was slow, feeble, and ir- 
regular. In some respiration was increased, rapid, and 
deep; in others it was slow and weak. In some the urine 
was full of sugar, albumin, and casts; in others it was perfectly 
normal. 

Varying from the velvety pink of the normal to the inelastic, 
flabby, mud-colored tint of the child in disease, the skin seemed 
subject to infinite variations and change. So was it with the 
muscles, some being normal, some rigid, some flabby. 

In one type of child with evidence of great cerebral involve- 
ment consciousness was markedly disturbed, and in another the 
sensorium was perfectly free. 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 183 

In these clinical studies Finkelstein brought out one fact, 
the importance of which long had been overlooked; namely, 
the child's weight curve (Fig. 7). To make a weight curve one 
must weigh the baby every few days, preferably every day, 
and plot out a curve upon a tabulated sheet, as one does for 
temperature, pulse, and respiration, or just as simply conceive 
it in the mind. These studies showed that weight curves 
were diagnostic of definite clinical entities. He called atten- 
tion to the curve of the healthy breast-fed baby, gaining 
steadily, the gain each day being like the one previous. He 



Days 




. 


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; 


J 


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i 


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1 




J 




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13 oz 

11 oz 

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7 oz 

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S 


y 

















































































Fig. 7. 



reminded us of the zigzag curve of the bottle baby, and sug- 
gested that this irregularity was due to the irregular retention 
and excretion of salts. You remember that cow's milk is richer 
than breast milk in mineral matter, and that being concerned in 
the retention of water in the baby's body, salts markedly in- 
fluence the weight. 



184 



INFANT FEEDING (CHICAGO METHODS) 



He showed a curve characterized by cessation of gain. He 
showed a curve characterized by gradual loss. He showed a curve 
characterized by acute severe loss. And, lastly, he showed 
the curve of a chronically sick baby, sick for weeks or months. 

These four curves (Fig. 8) are typical and practically diag- 
nostic of four distinct types of cases, each one of which might 
be produced through improper feeding. His entire classifica- 
tion is a comprehensive one, but for the present let's confine 



Bays 


1 


2 


3 


4 


5 


6 


7 


6 


9 


10 


11 








































t 
























































































































■s 


*>• 




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s 






















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Weeks 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 







































































Fig. 8. 

ourselves to this group which Czerny first introduced and 
Finkelstein so greatly enlarged, namely, " Disturbances of Nu- 
trition" on the basis of food. Why Finkelstein was not satis- 
fied with etiology as a means of classification he explains in his 
modest way by saying: "We are still in such a maze that it 
might perhaps be wiser, as a guide to us in further study, for the 
present to content outselves with clinical pictures. The truth 
is always to be found at the bedside." His classification of food 
disturbances is as follows: 



MODEKN CONCEPTION OF DISTURBANCES OF NUTRITION 185 

1. Failure to Gain. — Infants who, though not very sick, are 
not thriving nor gaining as they should. They usually have 
constipated, soapy stools and are subject to infections. 

2. Dyspepsia. — Here the picture is that of a mild diarrhea. 
The child is not very sick, but is a little peevish and irritable — 
the type which you gentlemen would call a mild gastro-enteritis 
or a mild summer complaint. 

3. Intoxication. — This is a very sick child. Diarrhea is 
marked; loss of weight, rapid and severe. Consciousness is dis- 
turbed, and the temperature high. It is much the same picture 
that you gentlemen, I presume, would call a very severe gastro- 
enteritis or a cholera infantum. 

4. Decomposition. — In this condition the child has been 
chronically ill with feeding difficulties. Nothing has agreed with 
him for weeks. He shows the great emaciation and under- 
nourishment of which the terms atrophy, malnutrition, and 
marasmus are descriptive. 

Not only are we indebted to Finkelstein for this beautiful new 
clinical classification, but we owe him everlasting gratitude for 
introducing into the study of disease a new food factor. Czerny 
introduced fat, and thought overfeeding in fat brought on milk 
injury, with its associated constipation. Finkelstein, with this 
same viewpoint, studied sugar, and it was his idea that over- 
feeding in sugar produced diarrhea. What a startling new con- 
ception this was! When he described to us the severe picture 
of intoxication, which you would call cholera infantum, and laid 
the cause of this hitherto deadly, often mysterious disease, 
simply to excess of sugar in the feeding, the interested profession 
was stunned, amazed, and unbelieving. In rapid succession, 
from all parts of the world, seeking to confirm or to disprove this 
view, innumerable new investigations and experiments were 
started, and although many of the original theories have been 
modified, the infinite value of this fundamental observation 
impresses us ever more and more. 

The third invaluable contribution of Finkelstein was the 
grouping of these four types under the head of " disturbances of 
nutrition." Like Czerny, when Finkelstein studied diarrheal 
disease and noted the changed pulse-rate, the changed respira- 
tion, the changed temperature, the disturbed consciousness, 



186 INFANT FEEDING (CHICAGO METHODS) 

and, above all things, the variable and impressive weight re- 
actions, we readily can imagine his reasoning: " Certainly this 
disturbance must be one involving more than the digestive 
canal. No matter, even though the origin be purely' gastro- 
intestinal, if every function of the body is involved and affected, 
we must think of the child as one in whom the entire nutrition 
is changed, and certainly such change must have great influence 
upon our treatment. Under no circumstance must we think of 
the gastro-intestinal tract alone." This viewpoint has been 
inestimable in directing our therapy away from the child's stool 
to that of the child's body. We believe that the stools are 
valuable symptoms of disturbance of the gastro-intestinal tract; 
but viewing our little patients from the broad conception of 
" disturbance of nutrition," after having noted the symptom of 
the stool, we often neglect it entirely, considering it only in its 
relation to the entire clinical picture. 

According to the viewpoint of Finkelstein, the grouping of 
diarrheal diseases as " disturbances of nutrition" must make 
stool examination absolutely incidental to the examination of 
the entire baby. The symptom of the stool sinks into insig- 
nificance beside the symptom of the baby as a whole. The one 
symptom representing the baby is the weight. The stool is a 
symptom to be considered, it is true, but not to be followed 
blindly. The weight becomes our index for treatment. * 

Finkelstein did not deny as a factor the influence of constitu- 
tion, which Czerny had suggested, nor the importance of in- 
fection; but he believed, first and foremost, that most disturb- 
ances were due not so much to constitution, not so much to 
infection, as to food; and when we say food we mean perfectly 
wholesome, good fresh cow's milk, given to the child, however, 
in improper dilutions. Whether one follows Czerny or whether 
one follows Finkelstein is immaterial. Both men have done the 
world a service for which generations to come must be grateful. 
From the point of view of the clinician the Finkelstein classi- 
fication is perhaps more practical. 

A crude illustration might make clearer the methods of these 
two men. Suppose we lived two hundred years ago, when dis- 
ease was considered due to evil spirits, to witchcraft, and to 
demons. Suppose at that time that out of the bewildering mass 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 187 

of ailments some great mind had become inspired with an idea 
of infectious disease, and to the eager world had exclaimed: 
"Some of these conditions are in a distinct group. They are 
'infectious diseases/ and exist as three types: 

"Those from pneumococcus. 
Those from streptococcus. 
Those from meningococcus." 

This is what Czerny did some ten years ago when, out of the 
bewildering mass of' ailing infants, he saw "disturbances of 
nutrition" and said they could be divided into three groups: 

Those due to constitution. 
Those due to infection. 
Those due to food. 

Finkelstein, on the other hand, had he lived two hundred years 
ago, when the above hypothetical individual had discovered 
"infectious disease," would have said: "I certainly agree that 
there is a great group of diseases due to infection. We know so 
little about them, however, that I think we had better stick to 
the clinical pictures and later we can worry about the causes." 
He then might have described, for example : 

Pneumonia. 
Meningitis. 
Septicemia. 
Rheumatism. 

He would have agreed that these pictures might each one be due 
to the pneumococcus, streptococcus, or meningococcus, but 
wouldn't have committed himself definitely. In the same way 
the Finkelstein classification recognizes "disturbances of nu- 
trition" and shows four clinical pictures: 

1. Failure to gain. 

2. Dyspepsia. 

3. Intoxication. 

4. Decomposition. 

He accepts the etiological factors offered by Czerny — con- 
stitution, infection, and food; but the advantage of his view- 
point is that he leaves the field more easily opened for further 
additions as to etiology. 



188 INFANT FEEDING (CHICAGO METHODS) 

Either classification is correct. It makes no difference which 
you follow; but from the clinical aspect the Finkelstein idea is 
perhaps more practical, for it resembles our clinical classification 
of infectious disease. As clinicians, what we seek first is a 
clinical picture. When we go to the bedside we do not ask 
ourselves, "Is this a disturbance due to pneumococcus or strep- 
tococcus or meningococcus?" but we do ask, "Is this a pneu- 
monia or a septicemia or a meningitis?" And having estab- 
lished that, then we seek the etiological factors. The beauty 
about a clinical classification is that it is true. Theories may 
be altered, ideas changed, new explanations advanced, but "in 
the clinic lies the truth." 

Having clean-cut clinical pictures, we are in a better position 
to seek causative factors. Just as in septicemia we have learned 
that much the same picture may be due to pneumococcus, strep- 
tococcus, or influenza, so can we amplify these clinical types of 
Finkelstein. This classification I, myself, do not believe to be 
the last word. I doubt if it will stay with us permanently; but 
it will be of invaluable help in further study. 

Having recognized these four clinical types, Finkelstein him- 
self began to seek causes — to fill in the subheadings. Stimu- 
lated by Czerny's description of fat injury and by his own dis- 
covery of the diarrheal effect of sugar, he attempted to place 
all four of these clinical pictures upon a food basis. In a crude 
way one might say his first idea was as follows (Fig. 9) : 



Failure To Gain 

i 

-Dyspepsia 




Intoxication*^- Decomposition*. 

Fig. 9. 

Failure to gain was due either to insufficient food or to over- 
feeding with fat. The latter was the very same condition that 
Czerny described as "milk injury," Finkelstein's term, how- 
ever, for reasons which we will discuss later, was "disturbed 
balance." Continuance of the overfeeding with fat led to the 
decomposition stage. Overfeeding with sugar led to the stage 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 189 

of ctyspepsia. If the overfeeding with sugar were continued in 
the stage of dyspepsia, intoxication resulted. If the mistake 
was overfeeding with fat in the stage of dyspepsia, decomposi- 
tion resulted. 

This viewpoint has been greatly modified. The hundreds of 
studies all over the world, stimulated by the novel idea, have 
brought great light. The all-important result of this first idea 
of Finkelstein was to bring the well baby and the sick baby 
closer together. The well baby can now no longer be secluded 
in his nursery, independent of all interest, only to come to notice 
when he shows abnormal symptoms. The well baby may at 
any moment, due to a little improper feeding, enter the group of 
sick babies. Let me impress upon you gentlemen, that Finkel- 
stein did not deny infections as a factor, did not deny constitu- 
tion as a factor; but of all things he did impress upon us the 
very, very great importance of food, and he attempted to show 
that many of the clinical pictures of even the very worst diar- 
rhea were due, not to external influence, but to the milk mixtures 
which we ourselves were feeding the baby. This, of course, has 
been of unspeakable importance in guiding our therapy and 
stimulating us to deeper thought. 

Finkelstein' s idea as to the importance of food has under- 
gone, during recent years, considerable revision. Continued 
studies from all parts of the world have introduced new and 
reemphasized old factors. Now we recognize many influences 
other than food. Finkelstein's latest classification is as follows : 
A. Food. 

I. Perfectly good, wholesome food, i.e., pure, fresh cow's milk. 

(a) Overfeeding. This may be of two types: 

1. Too great quantity. 

2. A preponderance of one of the elements of the 

milk, too much fat or too much sugar — the group 
which Czerny and Finkelstein called so strik- 
ingly to our attention. 

(b) Hunger. This may be: 

1. Insufficient total quantity. 

2. Insufficiency of one or more elements of the milk, 

as protein and salt deficiency in prolonged 
use of barley water and gruel. 



190 INFANT FEEDING (CHICAGO METHODS) 

II. Spoiled milk and food. The factor to which Czerny 
ascribed diarrheal disease, the one which Finkel- 
stein considered unimportant as compared to 
sugar in the diarrhea of nurslings. Both observers 
admit the importance of spoiled food in diarrheas 
of older children. 

B. Underlying Weak Constitution, or any factor weakening 

the constitution, such as heat, is an influence of 
no small importance. 

C. Milder Infections, such as coughs and colds, bronchitis, 

and cystitis, are important predisposing agencies. 

D. Nursing injuries may be of two types: 

I. The failure of the individual nurse in allowing her charge 
to suffer from improper care, from uncleanliness, 
from over clothing, overheating, or exposure. 
II. A weakness inherent to our hospitals is the infant ward. 
Here one nurse, no matter how efficient, is in charge 
of several babies. She cannot give each child 
the necessary individual care. She cannot take 
proper interest in the preparation of the bottles, 
nor give personal attention during feedings. The 
children, suffering from lack of exercise, resemble 
plants rather than animals, and each day approach 
more closely the danger of a disturbance of nu- 
trition. 

DIAGNOSIS 

How do we diagnose a nutritional disturbance? Besides care- 
ful physical examination, we have two valuable aids: 

1. A careful history. Information of frequent digestive dis- 
turbances, of frequent infections, improper care, a weak consti- 
tution, or backward development, would lead us to think 
strongly of nutritional disturbance as a factor in the present 
complaint. 

2. Above all things, gentlemen, never neglect, and learn to 
know, the reactions to food and to hunger. 

(a) In one child with severe diarrhea the addition of a full 
bottle of food may be fatal, the child dying, with a rapid loss 
of weight and with the severest symptoms of intoxication. In 



MODERN CONCEPTION OF DISTURBANCES OF NUTRITION 191 

this same child, the complete withdrawal of food for twenty-four 
hours seems to effect a rapid, striking improvement. It was, in 
a way, this so-called paradoxical reaction that first led Finkel- 
stein to the careful study of food in these diarrheal conditions. 
Addition of food kills : withdrawal of food saves. What better 
clinical evidence can we demand of the vital importance of food? 

(6) In some children complete withdrawal of food for twenty- 
four hours leads, with all symptoms of collapse, to rapid loss of 
many ounces of weight and death. 

Of these clinical pictures, of these weight curves, of these food 
reactions, we shall hear more. 

To conclude, we have learned this morning that in the great 
group of non-thriving children, the children with diarrhea, the 
children with constipation, pathological examination of the. 
intestinal tract as a means of classification is of little aid. We 
have learned that the science of bacteriology helps us but little. 
Czerny, with the conception of " disturbance of nutrition," 
takes our attention away from the intestinal tract, makes us 
think of the baby as a whole, and Czerny does us an infinite 
service by doubting the danger of protein and first calling to 
our attention the importance of food (of fat) in the production 
of the clinical picture of non-thriving, constipated children. 
Finkeistein, in a way following the footsteps of Czerny, arriving 
at these conclusions through careful clinical observation, im- 
presses us with the importance of all foods in causing these dis- 
turbances, agreeing with Czerny in some respects as to the 
effects of fat, and doing us immeasurable good in calling to our 
attention the diarrheal effects of sugar. Laying lesser stress 
upon constitution and infection in the production of these dis- 
eases, he believes disturbances of nutrition almost exclusively 
to be due to food — perfectly good, wholesome milk, but given in 
improper amounts and diluted in improper proportions. We 
can never be sufficiently grateful to him for placing diarrheal 
diseases also under the term " disturbance of nutrition." 

This magnificent conception is of inestimable value to us in the 
treatment of our children. From this viewpoint the stool be- 
comes a symptom, the baby as a whole becomes the important 
consideration. The stool becomes absolutely subservient to the 
whole clinical picture. Just think what this means! This 



192 INFANT FEEDING (CHICAGO METHODS) 

means we must never devote ourselves to the intestine alone, but 
only the intestine in relation to the whole body. In our deeper 
interest in the child's body we may be forced to do what seems 
to be worst for the intestinal tract. This viewpoint impresses 
upon us finally, irrevocably, the tremendous importance of the 
weight curve. The weight curve expresses the condition of the 
baby as a whole; the stool, only that of intestinal tract. 

With this conception of the fundamental importance of food, 
the well baby becomes a sick baby. The well baby may assume 
any clinical picture by varying his feeding. Gentlemen, if you 
will remember this, if you will only see your well babies more 
often, if you only will think of them as sick babies, will treat 
them with the same care and consideration that you would a 
patient with infectious disease, I can assure you that you will 
have little trouble with the babies, little trouble with the moth- 
ers, and the feeding cases in your practice will become a pleasure 
rather than a burden. 



LECTURE IV 

FAILURE TO GAIN 

Gentlemen, you remember in our last lecture we spoke of the 
viewpoints of the various great pediatricians. We told of the 
failure of the Vienna school to place nutritional disease upon a 
definite pathological-anatomical basis. We spoke of the failure 
of Escherich to find specific bacterial causes. Don't misunder- 
stand me, gentlemen; the ideas failed. The men succeeded. 
Patient, conscientious perseverance cleared away the obstacles 
that otherwise would have prevented the advent of newer con- 
ceptions. You remember it was Adalbert Czerny, the skeptic, 
the keen observer, the deep philosopher, who gave us newer 
thoughts. You remember he no longer spoke of disease of the 
gastro-intestinal tract. To him these disturbances were " dis- 
turbances of nutrition." The baby no longer was diseased 
solely in his stomach and intestines, but changes were effected 
in every sinew and fiber of the body. It was Czerny who, for 
the first time, cast doubt upon the orthodox idea of the in- 
digestibility of cow's-milk casein. It was Czerny who, for the 
first time, called to our attention the factor of food in the pro- 
duction of definite clinical entities. With two clean-cut clinical 
pictures he brought to our notice fat and starch. Too much 
fat was the causative factor in non-thriving, constipated in- 
fants; too much starch produced another clinical entity. It 
was Czerny who gave an etiological classification. You re- 
member the classification? Nutritional disturbances were 
those — 

a. On the basis of constitution. 

b. On the basis of infection; these were the diarrheal diseases. 
Two factors might be concerned: 

(1) True infection of the gastro-intestinal tract with germs 
of specific diseases, such as dysentery or cholera. 
13 193 



194 INFANT FEEDING (CHICAGO METHODS) 

(2) Poisoning, resulting from the drinking of spoiled food — 
food which had not properly been cared for and had become a 
great culture-medium for the common every-day organisms. 

c. Disturbances due to food: 

(1) Milk injury. 

(2) Starch injury. 

So, if we follow Czerny, we no longer speak of gastritis, gastro- 
enteritis, and cholera infantum; but rather of a disturbance due 
to constitution, due to infection, or due to food. 

In a and b he gave us etiological factors; in c he gave us an 
etiological factor with two beautifully described clinical pictures. 

You remember while this epoch-making work was being 
evolved, Finkelstein, in Berlin, was making great studies from 
a purely clinical viewpoint. 

In today's lecture I wish to discuss with you Czerny's "milk 
injury" and show how this has been modified by clinical obser- 
vation. 

Czerny's description roughly is as follows: A mother brings 
her infant, complaining that he is not thriving and that he is 
very constipated; she doesn't regard him as being sick: just 
wants a little advice. You, doubtless, have seen many such 
cases. Upon examination you find a rather pasty, not badly 
nourished, somewhat anemic-looking child. He is a little 
flabby. You think of a beginning rickets ; you place him upon 
the table and he flops over, showing a somewhat flaccid mus- 
culature. His weight is slightly below normal. Upon ques- 
tioning the mother you learn that he is not gaining as he used 
to; that he is a little peevish and fretful; he is subject to mild 
infections; and, above everything else, the mother dwells upon 
the constipated, dry, crumbly, soap-like stools, which charac- 
teristically do not adhere to the diaper, but easily can be brushed 
away. To the mother the chief trouble is constipation. 

You think the child is undernourished; you increase his diet; 
but he doesn't gain. Possibly he becomes more peevish and 
irritable, and the constipated stools more persistent. 

In seeking the cause of this condition, Czerny focused his 
attention sharply upon these abnormal bowel movements, and 
here he made a great discovery. You remember in our second 
lecture we spoke of the way in which fat normally leaves the 



FAILURE TO GAIN 195 

intestine; that a certain amount of it — a rather small percent — 
combines with alkalis, such as calcium and magnesium, and 
leaves in the form of soap. To Czerny's great interest, these 
stools contained a much greater percentage of soap than stools 
of normal babies. If the soap in a normal baby was perhaps 
20 percent of the fat of the stool, in these babies it might be 50 
percent. Czerny's reasoning was clear and simple. If a soap 
consists normally of fat combined with calcium or magnesium; 
if the stools of these children contain an increased amount of 
soap, then from these children there must be an excessive ex- 
cretion of mineral matter, of calcium and magnesium, and the 
general symptoms might be explained as a disturbance of nu- 
trition in which loss of mineral matter plays a prominent part. 
If the mineral matter combines with fat to form soaps, then by 
reducing the fat in the diet we should decrease soap formation 
and thus lessen mineral loss; by increasing fat in the diet, we 
should enhance soap formation and increase mineral loss. True 
enough, Czerny's assistants, by offering these children increased 
quantities of fat, were able to increase soap formation and cause 
greater mineral excretion. The solution to the question was 
now simple. All that was necessary was to diminish the amount 
of fat in baby's bottle, substitute some food of equal caloric 
value, and the child should thrive. To accomplish this, Czerny 
used a mixture known as Keller's Malt Soup, which is made as 
follows : 

(a) To one-third of a quart of milk add 1 ounce of ordinary 
flour. 

(b) In another mixture, to two-thirds of a quart of water add 
about 33^3 ounces of malt soup extract. In this country the 
latter is put up by Borcherdt or the "Maltine" concern. 

(c) Add the two mixtures together, boil, and you have in the 
resulting food an absolute cure, a perfectly ideal treatment. 
The baby's constipation subsides, the stools become normal, he 
gains in weight, and in every way becomes brighter and happier. 

The following curve, taken roughly from the text of Czerny 
and Keller, illustrates Czerny's idea (Fig. 10). 

This child is five months of age. From birth he got nothing 
but milk and water,, and was brought to the clinic for typical 
symptoms of milk injury. He did not sleep well, was restless, 



196 



INFANT FEEDING (CHICAGO METHODS) 



and showed the constipated, fat-soap stools. During the first 
half of February he received one-third milk; during the latter 
half, half milk, and during March, full milk. Notice here a 
slight rise in the curve, but it is not sustained. In April Keller's 
Malt Soup resulted in the astonishing rise. This Czerny at- 
tributed to reduction of fat. 

In taking up this subject I hesitated somewhat. Would it 
be wiser to go into detail, showing you the reasoning of these 
observers, or to state simply that "The symptoms are so and 
so, the treatment so and so." Upon consideration, however, I 
thought I should like to show you the fundamental "why" at 



Month 


Feb. 


March 


April 


May 


13 IDs. 
12 lbs, 
11 lbs. 
10 lbs. 


• • 






>- 


• • 


• 


CO / 


y 






V 








u 

3 








r-i 

3 





Fig. 10. 



the basis of these observations, because if you master the under- 
lying principles, you will have the key not only to the treatment 
of this particular condition, but also to many of the cases of 
constipation which perplex you in your daily children's practice. 
While these brilliant experiments were being conducted in 
Breslau, Finkelstein, in his institution in Berlin, was attacking 
the problem by careful study at the bedside, by accurate clinical 
observation. Perfectly independently he studied a great group 
of children, many of whom apparently were not very ill, all of 
whom showed a "failure to gain." In some, marked constipa- 
tion was present; in others, bowel movements were more nearly 
normal. In these studies, Finkelstein and the men influenced by 



FAILURE TO GAIN 197 

his teaching, showed that there were many factors featuring in 
the etiology. 

(1) Some children who showed the typical picture of Czerny 's 
"milk injury" were getting insufficient food; increase of quan- 
tity brought correction of the intestinal symptoms and speedy 
cure. This, strictly speaking, does not belong to the group we 
are discussing. I place it here, however, as did Finkelstein, for 
from a clinical standpoint in your practice you frequently meet 
such cases. In true "milk injury," as described by Czerny, in- 
crease in total food volume does not result in gain. 

(2) Some children recovering from ordinary infections showed 
this very same symptomatology. They had been thriving 
perfectly until taken ill with a cough or cold or mild cystitis, 
and upon recovery, with absolutely no change in diet, spon- 
taneously developed this disturbance. Here, then, fat alone or 
even the food, could not be blamed, for the baby previously had 
been gaining on the very same mixture. 

(3) In another group improper care of the baby, whether in 
the home or in the hospital, in some mysterious way seemed to 
predispose. The explanation is not as yet clear. You remem- 
ber we are confining ourselves to clinical observation. 

(4) A group of children who suffer with a weak constitution, 
congenital heart disease, or other hereditary anomalies easily 
progress to this condition. 

(5) Lastly, the group in clean-cut, definite form in which too 
much milk, or, as Czerny would have it, too much fat, seemed 
to be the important factor. 

Gentlemen, you already see what tremendous influence clinical 
observation exerted upon our interpretation of this condition. 
Czerny gave us the wonderful conception of disturbance of 
nutrition; then temporarily forgot it in his intense interest in 
the baby's stool, and overlooked other factors, perfectly inde- 
pendent of food, which might have been concerned. Finkel- 
stein and his students, in adhering to the broader conception, the 
original idea of Czerny, regarding the stool purely and simply 
as a symptom and not as a cause, were able to add much to our 
knowledge. 

Let us return for a moment to group (5) , the cases in which both 
Czerny and Finkelstein noted a rather high amount of fat in the 



198 INFANT FEEDING (CHICAGO METHODS) 

diet. The many observations and experiments stimulated by 
Czerny's novel conception began to bear fruit, but as time pro- 
gressed these observations and experiments gradually began to 
speak against the primary influence of fat. First was shown 
that in some cases, in spite of a high fat diet, in spite of the fat- 
soap stool, there was no total mineral loss to the body. True, 
the mineral matter in combination with fat was increased, but 
the mineral matter excreted in combination as salts was de- 
creased, and so the sum total was not above normal. 

A second argument against the primary importance of fat 
was the brilliant metabolic work of young Hans Barth, whose 
tragic death in the present war has been such a sad blow to 
modern pediatrics. He and his coworkers showed that in many 
cases the total amount of mineral matter lost in the form of 
calcium and magnesium was infinitely greater than could be ex- 
plained by the soap formation in the stool. 

And, lastly, comes the ever-valuable, unexplainable clinical 
evidence that children with well-developed, perfectly typical 
milk or fat injury can be cured in striking fashion by the 
use of breast milk. Breast milk, as you remember, contains 
the very same amount of fat as cow's milk. This is an unan- 
swerable argument. If a baby showing the picture of milk 
injury on cow's milk feeding can be cured at once by the use of 
breast milk, then fat exclusively, by itself, can scarcely be the 
sole factor in the etiology. We, blindly groping for explanation, 
must conclude that fat alone cannot be responsible, but fat plus 
some invisible mysterious element contained in cow's milk and 
not in breast milk. 

During the furor accompanying Czerny's discovery and the 
battles waged by his supporters and his critics, Freund was 
making brilliant, almost conclusive, experiments in his own in- 
stitution. He fed babies showing the typical picture of milk 
injury various foods, such as starch. This had little effect 
upon the stool. He fed them sugar of milk and malt ex- 
tract. Lo and behold! under the influence of the latter articles 
of diet the soaps disappeared; the fats were excreted in other 
combinations, and constipation was cured. This observation 
seemed uncanny — full of mystery. What could be the under- 
lying principle? Freund explains it in what seems very beauti- 
ful, simple reasoning. 



FAILURE TO GAIN 199 

Gentlemen, you remember in our previous lectures we dwelt 
upon the processes of putrefaction and fermentation. We spoke 
of the alkali-forming protein, of the rather non-fermenting 
higher carbohydrates, and the fermenting acid-forming lower 
carbohydrates. The substances which were of great influence 
in correcting the constipated stool were those aiding fermenta- 
tion, those tending to make the intestinal contents acid; and 
now Freund reminds us of a simple little chemical process which 
previously had been overlooked, viz., that fat does not readily 
form soaps in the presence of acids, but in a way combines with 
them to form the so-called fatty acids. Soaps in the presence 
of acids are completely split up, just as if they were salts. Gen- 
tlemen, do you grasp the importance of this contribution of 
Freund? Think of it carefully for a moment. If this be true, 
soap formation is a result and not a cause. Soap formation is 
simply a symptom of the intestinal reaction and not a factor 
affecting it. Feeding substances like protein, which alkalinize 
the intestine, favor soap formation and constipation. Feeding 
substances like carbohydrate, which make the intestine acid, 
break up the soap formation, and cause the looser type of bowel 
movement. Gentlemen, I urge you to give this matter careful 
consideration, to hold the principle before you at all times, 
because in mastering it you have mastered one of the great 
causes of constipation in infants. "Fat in an alkaline intestine 
forms soaps; in an acid intestine, fatty acid.'" 

And now, if this great mass of careful observation and scien- 
tific experiment proves to us that the constipated soapy stool is 
an effect and not a cause, are we any closer to a clearer under- 
standing of the picture of milk injury? With true American 
lack of respect for dignity and title one day I assailed Finkel- 
stein in a corner of his great institution, from which the modest 
little man could not escape, and asked him to make the matter 
clear to me. I never left him until, filled with wonder and ad- 
miration, I had obtained his own personal viewpoint. He re- 
minded me that in feeding a baby we must consider the food, 
the intestine, and by all means that factor which so frequently 
and at such tremendous cost is overlooked by men speaking 
exclusively of " gastro-intestinal disease" rather than " dis- 
turbance of nutrition, " — the needs of the child's whole body. He re- 



200 INFANT FEEDING (CHICAGO METHODS) 

minded me that in feeding Keller's Malt Soup one reduces the 
fat, but at the same time increases markedly the carbohydrate. 
Simple reasoning, simple skepticism, forces the question, "How 
does one know that this gain, that this recovery, was due to the 
reduction of fat? Is it not just as reasonable to assume that 
the increase of carbohydrate was a factor of equal or even greater 
importance? Is it not likely that children with weak constitu- 
tions, children recovering from infections, children suffering 
from neglect, need more carbohydrate, more energy, than does 
the normal baby? Is not the primary consideration in these 
cases the demands of the child's body rather than the condition of 
his digestive tract?" Have you forgotten the striking statement 
of Naunyn, "The fat burns in the fire of the carbohydrate"? 
With such a remarkable viewpoint, the condition of the digestive 
tract fades into insignificance before the primary consideration 
of the child's body. The child's vigor and strength depend upon 
the amount of carbohydrate offered, and are perfectly inde- 
pendent of the reaction of the intestinal tract. Whether the 
fat in the stool is excreted in the form of soap or whether it is 
excreted as fatty acid depends upon the reaction of the intestinal 
contents. If the contents are alkaline, soaps are formed; if 
acid, fatty acids result. In Keller's Malt Soup we have a 
mixture ideal for creating an acid condition in the intestine. 
Low protein from the dilution of the milk lessens alkali forma- 
tion; high carbohydrate favors acid. Due to this acid, the fat 
soaps are split up and constipation corrected; but the great 
benefit to the child — the gain in weight, the improved tone of the 
muscles, the returning elasticity to the skin — depends not upon 
the correction of the stool, but upon the increased supply of 
carbohydrate offered to the needy tissues. 

It was for this reason that Finkelstein introduced the term 
"disturbed balance." He meant to imply that the primary 
fault was not one of fat injury, was not one of chronic fat in- 
digestion, as is the viewpoint of so many men, but that the 
trouble lay in a disturbed balance between carbohydrate and 
fat, perhaps carbohydrate and protein, the body not receiving 
enough carbohydrate to satisfy its wants, probably not receiv- 
ing enough carbohydrate to perform successfully the metabolism 
of the fat. This viewpoint in a striking way makes clear to us 



FAILURE TO GAIN 



201 



the brilliant success from feeding of breast milk. Breast milk 
offers the body high carbohydrate; breast milk, with its high 
carbohydrate and low protein, establishes processes of fermen- 
tation in the intestinal tract and cures the constipation. 

This viewpoint, perhaps, does not explain every case; perhaps 
some cases really are due to primary fat indigestion; but at 
any rate we learn much from this conception, and a great group 
of cases becomes clear. Probably in the majority of cases, as 
shown by the results with breast milk, the fat is indeed only a 
secondary factor. 

Gentlemen, now you see why I have tried to go into detail. 
If you have followed me carefully; if you have understood the 
principles which I am trying to make clear, you have the key 
to the majority of cases of constipation which you meet. 

You see also how modern clinical medicine can never be 
separated from chemistry, physiology, and the allied sciences. 
The physician needs them all for complete understanding. 

The diagnosis of this condition is easy. In practice you will 
have to distinguish it only from inanition, i. e., hunger; in the 
latter, an increase of a half-ounce or an ounce to each feeding 
will result in rapid cure. In the true case of disturbed balance 
no improvement follows. 

Treatment. — For the young baby breast milk, which is always 
the ideal food, is the best treatment. In offering breast milk, 
let me warn you of a little complication, simple in physiology, 
ignorance of which, however, may lead to unpleasant results. 
To illustrate (Fig. 11): 



7 02 

6 oz 
5 oe 
4 oz 
3 oz 
t oz 
1 oz 












































































A 




































































\ 








— > 


\ 


































\ 




































V 


s. 

























































Fig. 11, 



202 INFANT FEEDING (CHICAGO METHODS) 

At A we have changed the mixture of cow's milk to one of 
breast milk. A loss of several ounces occurs, lasting several 
days. What is the explanation? Can any of you grasp why a 
loss of weight should result from feeding breast milk? The 
answer is found in the simplest physiology. In our first lecture 
we told you that cow's milk was much richer in mineral matter 
than breast milk. In our second lecture we told that minerals, 
particularly sodium, were important in binding water to the 
tissues. If our baby had been getting a mixture of three-quar- 
ters of a quart of cow's milk, he would be getting 5.7 grams of 
salt — over a teaspoon. The change to three-quarters of a 
quart of breast milk reduces his salt intake XoV/i grams. You 
see what reduction occurs in the mineral matter of his diet. 
For this reason, until he gets properly adjusted, water leaves the 
body, with the resulting drop of several ounces in the weight 
curve. This loss is not due to poor breast milk, is not due to 
insufficient breast milk, but to perfectly normal breast milk, and 
a knowledge of the simple explanation will save the mother, the 
wet-nurse, and incidentally you, much worry. 

If artificial feeding is to be employed, what shall be our pro- 
cedure? Do we need Keller's Malt Soup? No; but we do 
need the principles upon which it is based. We wish to offer 
more carbohydrate, more energy to the baby's tissues; we wish 
and must do this without injuring the intestinal tract. In our 
next lecture we shall learn that mixtures of high carbohydrate in 
connection with high fat, particularly in connection with concen- 
trated whey of cow's milk, are dangerous from the intestinal 
viewpoint. We, therefore, dilute our milk, not with the idea of 
diluting the fat exclusively, but of simply making up a mixture 
which will enable us to offer to the tissues higher carbohydrate 
without causing intestinal complications. We dilute to one- 
third, adding two-thirds water, and then gradually increase 
carbohydrate until we get the improvement of the general con- 
dition and the more normal stool. Ordinary cane-sugar is the 
simplest and cheapest carbohydrate to use. One word of warn- 
ing, however, in employing it. It may become necessary to add 
more than six or eight teaspoons to a quart of the mixture in 
order to get the physiological results. Under such circum- 
stances the mother and babe rebel at the sweet taste; therefore, 



FAILURE TO GAIN 203 

if it becomes necessary to increase over six to eight teaspoons, 
it is wise to add some easily fermentable carbohydrate less sweet 
to the taste. This can be done in the form of the above-said 
malt soup extract. Don't make the mistake, however, of order- 
ing pure malt extract. This does not mix so readily with the 
milk, and you may get into difficulties with the mother; but 
show your superior knowledge by impressing her with the neces- 
sity of getting malt soup extract. Several concerns put this up. 

In children over two or three months of age, remember that 
one-third milk is not sufficient to provide for continued growth. 
After a short time one cautiously must increase the concentra- 
tion of the milk. The increased protein temporarily may cause 
an alkaline reaction to the intestine with a renewal of soap for- 
mation and constipation. This can be combated readily by 
additional increase of carbohydrate. 

One point in the treatment, let me impress you, is what you 
should not do. Now that you understand the underlying prin- 
ciples, you see how utterly unreasonable, how absolutely with- 
out scruple, is the physician who drugs these patients, treating 
their constipation with calomel, castor oil, and other cathartics. 
At our hospital at home Dr. Abt and his associate, Dr. Jampolis, 
some years ago made interesting observations on perfectly 
normal babies. Feeding a fine healthy baby a therapeutic dose 
of these drugs caused the appearance of blood in the stool — not 
in large quantities, but easily detected chemically. Just think 
of that, gentlemen; feeding a perfectly healthy, normal infant 
medicinal doses of calomel produces such irritation in the in- 
testine as to make blood appear in the stool! What a crime is 
it, then, to offer a little child suffering from a condition of dis- 
turbed balance these strong intestinal irritants; to try to over- 
come constipation, not by reason and principle, but by brute 
force! What this baby needs is not medicine: he needs sugar. 

Gentlemen, we are now temporarily going to leave Czerny. 
Remember his great service to us — his service in giving us the 
conception of disturbance of nutrition; his service in casting 
doubt upon the indigestibility of protein; his service in recog- 
nizing food as an important factor in nutritional disease. What 
have we learned from this lengthy, perhaps complicated, dis- 
cussion? We have learned to think. Only the light shed by 



204 INFANT FEEDING (CHICAGO METHODS) 

time, by distance, by laboratory experiments, stimulated by 
the keenest clinical observations, could make us change alle- 
giance to Czerny's first idea. Every great pediatrician who 
was able to read these writings and comprehend them was in- 
fluenced. The very foundation of pediatrics was shaken. Now, 
from across the space separating us by years from Czerny's 
first work we ask ourselves, "Did we not all err alike? Did 
we not all make the same fundamental error?" We were stirred 
by the brilliant conception of disturbance of nutrition; we 
temporarily lost sight of this in our keen interest in one symp- 
tom — the stool. In focusing our attention upon the stool we 
lost all sense of proportion in the discovery of the soap. In 
this maze of thought we lost sight of the relation of fat to the 
other elements in the milk; we lost sight of the fact that fat in 
an acid intestine makes fatty acids; in an alkaline intestine, 
makes soaps. Not that our observations were without value or 
interest: much good has resulted. But they were in entire 
disproportion to the great clinical picture. Only careful, fre- 
quently repeated, accurate bedside study resulted in putting 
us again upon the right path. Just as we had forgotten to note 
the relation of the fat to the other elements of the milk, so had 
we forgotten to note the relation of the symptom — the consti- 
pated stool — to the main clinical picture. Just as our exclusive 
attention to the fat had led us astray, so did our exclusive at- 
tention to the stool divert us from our original broad conception 
of disturbance of nutrition. Gentlemen, what have we learned? 
We have learned that if we wish to err only slightly, if we wish 
to have an anchor that will hold us secure, let us never forget 
that first, foremost, above everything else, the fundamental 
truth is to be found in careful, conscientious clinical observation 
and study. 

What is the practical significance of this lengthy discourse? 
If a constipated baby is not gaining upon a well-regulated diet, 
carefully increase it. If he still does not gain, make up a mix- 
ture with a higher percentage of fermentable carbohydrate 
than was contained in the original formula, and increase gradu- 
ally this carbohydrate until improvement occurs. 



LECTURE V 
THE STATES OF DYSPEPSIA AND INTOXICATION 

Gentlemen, if our last lecture was important from a stand- 
point of therapy, today's lecture is vital, for it concerns life. 
You remember at our last meeting we spoke of Czerny's new 
viewpoint, " disturbance of nutrition." We showed how he 
introduced food as a factor in causing disease and how he laid 
particular importance on fat. He doubted the indigestibility of 
protein; he gave us an etiological classification; due to this 
etiological classification, to this concentration, perhaps, on one 
causative factor, we became side-tracked and focused too care- 
fully upon one symptom — the stool. Finkelstein, you re- 
member, accepted the viewpoint of "disturbance of nutrition," 
agreed that infection and constitution were factors, but enlarged 
greatly the importance of food. To him most disturbances, 
including even the diarrheas, were due not to infections, but 
practically entirely to food alone. Clinical pictures to be 
brought about by improper feeding were four: 

The picture of milk injury he saw just as did Czerny, but for 
reasons which we stated he changed the name to " disturbed 
balance." His tremendous contribution in this realm was in- 
cluding diarrheal disease in this group. To him the majority of 
diarrheas do not belong to the infectious group of Czerny; do 
not belong either to (a) those caused by specific bacterial in- 
fection of the intestine or to (b) those resulting from milk 
spoiled by bacterial growth, but do belong to the group of dis- 
turbances arising from the feeding of good, wholesome, pure 
milk made into improper mixtures. 

The history of the observation and development of the food 
basis for diarrhea is fascinating. The first stimulus came to 
Finkelstein and his assistants with the appearance, in their 
great institution, of a number of cases of severe diarrhea — 
gastro-enteritis, as they might then have been called, or dis- 

205 



206 INFANT FEEDING (CHICAGO METHODS) 

turbances of nutrition on the basis of infection, as Czerny would 
have said. Perhaps, in a way, it was Czerny's conception of 
food disturbance that led them to investigate carefully condi- 
tions in the diet kitchen. To their interest and amazement 
they discovered that by an error, many mixtures contained 
unusually high quantities of sugar. Could the sugar be a causa- 
tive factor? 

Full of curiosity, they fed babies large quantities of sugar, 
produced severe diarrheal disease, and gave to the pediatrics 
world one of' our most wonderful contributions. Not only could 
high fat and low sugar produce a condition of disturbed balance, 
but high sugar, on the other hand, could produce severest diar- 
rheal disease. For the moment we see Finkelstein following the 
same error of Czerny, focusing too carefully upon the stool, 
upon one symptom, forgetting the big clinical picture and laying 
blame for almost every case of bad diarrhea on too much carbo- 
hydrate in the food. Not long, however, before he saw his error. 

The same objection applied to this view as did to the original 
idea of Czerny. Breast milk, the ideal food, contains a large 
quantity of carbohydrate, — easily fermentable carbohydrate, — 
but children when fed breast milk do not develop these deadly 
diseases. There must be some other factor — some other in- 
fluence. This is simple reasoning, simple common sense. Care- 
ful clinical study again guides us along the right path. 

At this time Ludwig F, Meyer, Finkelstein's first assistant, 
made an important contribution. While his experiments are 
open to great criticism; while in the light of our present knowl- 
edge they can be attacked from all sides, nevertheless, in their 
day they served their purpose. He took cow's milk and breast 
milk, separated them each into curd and whey, as, for example 
(Fig. 12), 

Breast Milk Casein^ -^Whey 

Cow's Milk Casein^ ^Whey 

Fig. 12. 

and after having divided these mixtures, he crisscrossed, adding 
the casein of cow's milk to the whey of breast milk, and the 



THE STATES OF DYSPEPSIA AND INTOXICATION 207 

casein of breast milk to the whey of cow's milk. Offering these 
mixtures to children sick with diarrheal disease resulted in sharp 
differences. Those getting the mixture containing the whey of 
breast milk made good recoveries; those getting the mixture 
with the whey of cow's milk did not do so well. 

Gentlemen, although this experiment is open to great criti- 
cism, it served its purpose. It called to our attention, for the 
very first time, the whey of cow's milk. Xow we hear of the 
whey as a factor in producing disturbance. We have heard of 
protein, fat, carbohydrate, and now we hear whey; and, after all, 
is it not strange that for so many years we have neglected this 
portion of the milk? Is it not likely that whey, with almost 
four times the salt content of breast milk, also could exert harm- 
ful influences upon the intestine, perhaps due to osmotic con- 
ditions or to who knows what? • To Ludwig F. Meyer, then, 
are we indebted for this new inspiration. 

While these observations were going on, clinical study again 
was bringing Finkelstein toward the ultimate truth. Increasing 
carbohydrate in some milk mixtures resulted in diarrhea. In- 
creasing carbohydrate in others, to his mystification, had no 
such effect. What could be the explanation? The solution 
was discovered in combining the above two clinical experiments. 
When carbohydrate is added to mixtures of cow's milk rich in 
whey, diarrhea results; when carbohydrate is added to mixtures 
poor in whey, no diarrhea results. The more concentrated the 
whey, the worse the diarrhea! Thus, you see, adding carbo- 
hydrate to buttermilk or to skimmed milk will make a laxative 
combination — these mixtures containing all the whey elements 
of the milk. Adding carbohydrate to pure whey would cause an 
intense diarrhea. I should advise you not to try this. What 
factor in the whey causes these symptoms I do not know. Per- 
haps it is the salt. As I have said so frequently, "This is clinical 
observation." 

It is human, however, to wish things clear; to have a picture 
to hold before us, a guide for our thoughts. I can offer the 
explanation that has been given by our teachers. Do not 
take it as an absolute truth, but simply as an illustration of the 
processes of modern reasoning. How can a mixture of whey and 
carbohydrate produce these results? 



208 INFANT FEEDING (CHICAGO METHODS) 

Normally, billions and billions of bacteria live in the large 
intestine. The small intestine is relatively sterile. Only at 
times when food is digested are bacteria found in any amount 
in the upper tract. With the disappearance of food, with its 
absorption through the intestinal wall, the bacteria rapidly go 
back to their home, to their normal environs in the large in- 
testine. Those left in the upper tract are killed, probably by 
the intestinal cells and by the digestive juices. 

Postmortem examination in many cases of severe diarrhea, 
however, reveals the upper intestine swarming with micro- 
organisms — not abnormal ones, but simply those which normally 
live in the lower bowel. Gentlemen, what has happened? 
Normally the upper intestine is able to keep its contents sterile. 
Something must have impaired this function. Is it not possible 
that the digestive juices and the activities of the epithelial cells 
have been handicapped by the high salt content, perhaps by the 
changed salt relations of the cow's-milk whey? Moro's experi- 
ments would tend to confirm this hypothesis. In carefully 
conducted researches he and his assistants showed that the in- 
testinal cells are more efficient when active in a medium of 
breast-milk whey than of cow's-milk whey. 

Once injured, these intestinal cells cannot suppress bacterial 
growth. Bacteria will thrive and prosper, and now, when car- 
bohydrate is introduced, before the intestinal digestive enzymes 
can alter it, prepare it for assimilation, and carry it through the 
intestinal wall, the hungering bacteria have seized it, fermented 
it, and changed it to the irritating lower fatty acids, such as 
acetic, butyric, and formic. Gentlemen, do you remember that 
in the first lecture and in the second, also, we tried to impress 
upon you that when bacteria attack carbohydrate the process 
is known as fermentation and acid results? Now you under- 
stand why. The injured intestinal epithelium can no longer 
exercise control and fermentation proceeds rapidly. A tremen- 
dous quantity of irritating products results, and causes a severe, 
acid, watery diarrhea. Such is what we reasonably may be- 
lieve. Clinical observation has painted a picture in abnormal 
physiology. 

To return to the bedside. Diarrheas are of two types: 



THE STATES OF DYSPEPSIA AND INTOXICATION 209 

(a) A mild attack, with symptoms described as mild gastro- 
enteritis or mild summer complaint. 

(6) An intense attack, often deadly in nature, described as 
severe gastro-enteritis, severe ileocolitis, or cholera infantum. 

The first of these conditions Finkelstein called dyspepsia; the 
second, intoxication, not because he had isolated any toxin, but 
because from a clinical point of view the little patient appeared 
poisoned. This, you remember, is a clinical classification. The 
picture is constantly before us. Explanations will be varied, 
causes amplified, new factors discovered ; but the clinical picture 
remains unchanged. 

DYSPEPSIA 

This is one of the most frequent ailments you meet. The 
mother brings the babe mainly for relief of intestinal symptoms. 
The child has mild diarrhea — five, six, or eight watery, green, 
sour-smelling stools with mucus; vomits occasionally and has 
colic. 

Careful history shows nothing of importance other than per- 
haps a slight cold. Baby's sleep is disturbed, and for a few days 
he has not been gaining. 




Fig. 13. 

Examination (Fig. 13) shows that he is not very sick — he is 
slightly undernourished, pale, and restless, perhaps peevish and 
irritable. Consciousness is not affected. There may be shadows 
14 



210 INFANT FEEDING (CHICAGO METHODS) 

under the eyes and the abdomen distended. Temperature, 
pulse, and respiration, other than possibly a slight fever, reveal 
no important change. 

Gentlemen, we have spoken about the reactions to food and 
to hunger. Addition of food or increase of diet to this patient 
will have little effect. His diarrhea may become worse, his 
general symptoms a little increased, but he will show no radical 
change. Withdrawal of food — absolute hunger — causes a marked 
improvement. Diarrhea ceases and he becomes better, brighter, 
and happier. There may be a moderate loss of a few ounces of 
weight for a day or so, but then the curve rapidly swings to 
normal. 

If we study such a child from a standpoint of metabolism; 
if we analyze carefully the amount of food taken in twenty-four 
hours and the end-products excreted in the urine and the stool 
for twenty-four hours, we find the following changes: 

a. Protein excretion is slightly increased. 

b. Fat is not changed unless the child has been receiving 
some quantity in his bottle. Then considerable is found in the 
stool. 

c. Starch may be found in the stool, particularly if baby has 
been receiving a starchy diet. 

d. There may be a slight loss of mineral matter, chiefly of 
sodium and potassium. 

e. Most striking is the increased excretion of the irritating 
volatile lower fatty acids, such as acetic, butyric, and formic. 

What is the source of these acids? Czerny would have said 
that they come from bacterial infection of the milk outside of 
the body; Finkelstein, that these acids are produced by the 
normal bacteria of the intestine attacking the carbohydrates of 
the milk under the accelerating influence of the whey. The 
splendid studies of the younger men, such as Barth, Edelstein, 
and others, stimulated by these controversies, have shown that 
acid formation in the stool is infinitely greater than acid 
formation in spoiled milk. Thus they must be created in the 
body. 

Just as clinical study enlarged Czerny 's idea of fat injury, so 
did it enlarge Finkelstein's idea of whey-sugar injury. New 
points added as etiological factors are: 



THE STATES OF DYSPEPSIA AND INTOXICATION 211 

I. From the Standpoint of Food. 

A. As regards good, wholesome, pure milk, the factor 
which Finkelstein so emphasized: 

(1) Simple overfeeding is a frequent cause. 

(2) Particularly is overfeeding with sugar-whey mix- 
tures a factor. This was Finkelstein's first great con- 
tribution. 

(3) In a medium of cow's-milk whey, high sugar plus 
fat causes these diarrheas. Many men lay primary 
emphasis upon the latter, for the stools show great 
quantities of undigested fat. We do not wish to be 
dogmatic. Undoubtedly high fat, particularly if not 
properly digested, can produce irritating products and 
diarrhea. We believe, however, the more important 
process is the primary fermentation of the carbohy- 
drate, which whisks out the fat in the resulting diar- 
rhea, the fat appearing as a neutral secondary element. 
We believe that probably the fat suffers secondarily 
as the acids from sugar fermentation interfere with 
the digestive enzymes. These, you know, work best 
in an alkaline medium. 

B. As Regards Spoiled Food. — From the viewpoint of 
Czerny, spoiled milk undoubtedly at times provides irri- 
tants to the intestine sufficient to cause these symptoms 
— particularly in older children, during the summer 
months, are spoiled foods of all sorts important agents. 

II. We have relearned the value of constitution. The weaker 
the baby, the more is he predisposed. 

III. Frequently repeated mild infections, as coughs and colds, 
are of extreme importance. 

IV. Heat and improper nursing must meet with our consider- 
ation, and, of course, time will add new influences to the 
list. Probably all of these in some way or another will 
increase fermentation in the intestines. 

From this viewpoint you see how relatively unimportant is 
examination of the stool — I mean, relatively unimportant as a 
strict indication for therapy. In any of these dyspeptic stools, 
had the baby been fed starch, the starch-granules would have 
been whisked through by the increased peristalsis; had he 



212 INFANT FEEDING (CHICAGO METHODS) 

received high fat, the fat would have appeared in large quanti- 
ties. Had we focused our attention exclusively upon the stool, 
forgetting the more general considerations, we would have said, 
"This is a disturbance due to starch; this is a disturbance due 
to fat"; but now, as Ludwig F. Meyer in his pointed way once 
said to me, "When you find high fat in the stool, seek the carbo- 
hydrate." 

Treatment. — The treatment based upon these opinions must 
be self-evident and simple. If the whey is a factor injuring the 
intestine and permitting bacteria to nourish in the upper tract, 
it must be diluted. If carbohydrate ferments, we must give it 
in a non-fermentable form. The more we dilute the whey, the 
more we reduce the factor injuring the intestine, the safer is 
it to give carbohydrate. Non-fermentable carbohydrates, we 
told you, are composed of mixtures of dextrin and maltose and 
can be offered as Mead's Dextri-maltose. More fermentable 
are Mellin's Food, Horlick's Malt Food (not Malted Milk), etc. 
Remember, these substances are carbohydrates, and under no 
circumstances baby foods. Dextri-maltose, copied from Soxh- 
let's Nahrzucker, contains most dextrin, and is therefore the 
least fermentable. Borcherdt also puts up a similar prepara- 
tion. 

Our treatment then for these milder conditions would be: 

1. Hunger for twelve to twenty-four hours, not forgetting, 
however, to keep up a sufficient supply of water. During this 
hunger period the baby's vomiting and diarrhea empty his 
digestive tract of all irritants. It is not necessary to give calo- 
mel and castor oil, unless, perhaps, foreign substances have been 
eaten; for the baby, as a rule, can well take care of himself. 
If you suspect that the trouble is due not to milk, but to corn 
or cucumbers or watermelon, a dose of castor oil and a mild 
colonic flushing may do no harm, if given once. 

2. After this hunger period we start food. To dilute the whey, 
we give one part milk, two parts water. To this mixture we add 
1 or 2 percent of non-fermentable carbohydrate. We boil these 
together and in six feedings give a total of six to ten ounces in 
twenty-four hours, always keeping up the supply of water. We 
gradually increase about three ounces to the total every day or 
two until we have reached the maximum, depending upon the 



THE STATES OF DYSPEPSIA AND INTOXICATION 



213 



baby's age. Then gradually we increase the carbohydrate to 
5 percent. In all this treatment our guide must be not so much 
the stool as the baby's weight curve (Fig. 14). 



Bavs 




1 S 






5 


i 


I 






1 


5 


1 




6 




i 


) 


1 





1 


1 




12 oz 

8 Oz 
4 oz 














































/ 




















































































































































i 


i 




i 






_1^_ 





















































































































Fig. 14. 



At A we have withdrawn food; a loss of perhaps seven to 
eight ounces results during the next few days. 

At B, after twelve to twenty-four hours' hunger, we give a 
day's total of six to ten ounces. We make no change until at 
C the curve has straightened, and then we cautiously increase. 
Remember, the curve is the index of the general nutrition, and 
although this dyspepsia is almost exclusively a local intestinal 
affair, still the loss of weight resulting from improper treatment 
proves that the general nutrition also can and does suffer, and 
if we keep this broad picture before us we shall less likely err 
badly. 

In some cases physicians, instead of giving water during the 
first day, give cereal waters — barley gruel, etc. This often is 
fully as efficient as plain water. The dangers, however, are 
two: 

a. The physician, in his carelessness, the mother not knowing 
that barley water is a starvation diet, forgets to add food, and 
allows the baby to remain on barley water for days. After a 
period of four, five, or six days the child rapidly develops the 
condition of Czerny's starch injury, or, as we shall call it, 
"decomposition." 

b. Sometimes, after the baby has been on barley water, for 



214 INFANT FEEDING (CHICAGO METHODS) 

reasons which are not clear, upon the addition of milk to the 
diet, fermentation again becomes active in the intestine and 
diarrhea returns. 

For dyspepsias in older children the same principles hold good. 
We shall refer to them later. 

Gentlemen, suppose we are ignorant of the food factor in this 
dyspepsia; suppose we have attributed the condition to some- 
thing else; suppose we have quieted the child with opiate and 
allayed the mother's fears; suppose we have thoroughly cleaned 
out the child with calomel and castor oil; and then suppose, in 
our folly, thinking the baby must have food, we offer the child 
one of those mixtures high in the whey elements of the milk and 
rich in fermentable carbohydrate, such as buttermilk with sugar 
or skimmed milk with sugar — can you grasp the result? 

Shortly we are called to see a desperately sick baby. The 
child is feverish and lies in semi-stupor. The sunken cheeks, 
the sharp nose, the ashen, mud-colored, wrinkled skin, the cold 
extremities, all show great loss of weight and great prostration. 
Intense watery diarrhea drains the body of its food, pulls out 
the very building-blocks of the tissues. The pulse is rapid and 
weak. Lying apathetically, our little patient takes not a par- 
ticle of interest in his surroundings. The unclosed lids show the 
glassy eyes fixed unintelligently upon one corner of the room. 
Occasionally he wakes for a moment, looks at us, cries fretfully, 
and again wanders off into apathy. The breathing is charac- 
teristic, deep, tireless, rapid, unceasing, like the air-hunger of 
diabetic coma. Occasionally one of the almost limp extremities 
moves slightly. Sometimes it takes a cataleptic attitude. The 
arms, particularly, are apt to assume the position typical of a 
prize-fighter. The urine may show sugar, albumin, and casts. 

Examination reveals an enlarged liver. 

What have we done? We have produced a wonderful, a terri- 
ble, clinical picture. We have produced the " alimentary intoxi- 
cation" of Finkelstein. 

Gentlemen, we spoke about the importance of food reactions. 
Listen carefully: If in this stage we offer our patient a full 
bottle; if we offer him any large quantity of food, his weight 
curve sinks precipitately, vertically, downward to rapid death. 
We have killed him. No surer way have we of doing this than 



THE STATES OF DYSPEPSIA AXD INTOXICATION 



215 



by offering food; no surer way have we of saving him than by 
removing food (Fig. 15). 



Days 


3 


. 


2 




j 




4 




i 




> 




1 


? lb 
12 oz 
8 oz 

4 oz 
6 lb 

12 oz 
8 oz 
































































^^ 






















































































































\ 




























\ 




























\ 


B 














































































































^ 


C, 











Fig. 15. 



In the period of his dyspepsia, if at point A we have mis- 
treated our patient, so that steady progression has thrown him 
into the stage of intoxication, at B addition of food brings the 
fatal drop; withdrawal of food straightens out the curve and 
the child is saved. What more beautiful illustration has one of 
the effects of food than this clinical observation — than this so- 
called "paradoxical reaction of Finkelstein"? The food which 
would cause a normal baby to gain, causes destruction; the 
hunger which causes a normal baby to lose, is salvation. 

What processes are involved in this radical change, in the 
progress of the mild dyspepsia to the deadly intoxication? Lis- 
ten carefully: This progress is one of transition from a mild, 
local, intestinal disturbance to the severest " disturbance of 
nutrition." In the dyspepsia, constitutional symptoms are 
mild. The acids formed slightly irritate the mucous membrane 
and cause diarrhea, but nutrition is not badly affected, as shown 
by the relatively slight loss of weight. Now note the progress. 



216 INFANT FEEDING (CHICAGO METHODS) 

Increasing acid formation injures the intestinal wall. The acids 
become sufficient to interfere with the digestive enzymes. Fat 
no longer is properly digested, and its split products aid in in- 
creasing the damage. In this acid medium new types of bac- 
teria nourish — bacteria which can attack the fat, producing 
intense irritants. 

Before these combined assaults the intestinal wall begins to 
fail. The membrane remains no longer impermeable to attack. 
Its weakened strength cannot be detected by the microscope: 
it can be by physiological experiment. Now for the first time 
undigested food-substances pass the membrane into the body. 
We have not seen these substances enter, but our examinations 
have found them as they leave. We feed children in this con- 
dition lactose, and lactose appears in the urine. We feed foreign 
protein, and foreign protein reappears. Gentlemen, the process 
of digestion is to prepare food-stuffs for the use of the tissues. 
Undigested food circulating in the body fluids is poison. See 
the possibilities of this conception. The mild dyspepsia has 
progressed so that now the entire body has become severely and 
dangerously involved. 

We can paint any picture. We see undigested protein and 
poisonous products of the fat taken into the circulation. We 
see the tissues bathed in strong solutions of sugar and of salt. 
We see innumerable products of bacterial activity rapidly enter- 
ing the system. We see chaos where we should see order. 

Small wonder at the multitude of clinical symptoms. Con- 
vulsions, strabismus, and cerebral cry may suggest meningitis. 
Gastro-intestinal effects may be great enough to resemble 
cholera. But in all cases remember that certain symptoms will 
be constant : the rapid loss of weight, the acidosis breathing, the 
disturbed consciousness. 

The examination of the intake and the total excretion of these 
children, in contrast to the mild dyspepsia, shows considerable 
loss of body substance. Protein, fat, and minerals are thrown 
out by the rapid intestinal movements. The urine shows the 
most profound changes of metabolism. There is a tremendous 
loss of water, due, perhaps, not so much to the increased bowel 
movements, for this loss is compensated by the decreased urine, 
but to the tireless, rapid, deep respiration. In this condition, 



THE STATES OF DYSPEPSIA AND INTOXICATION 



217 



then, we are dealing with an infinitely more important problem 
than local intestinal disease. As tonsillitis results in endocar- 
ditis ; as the insignificant wound ends in deadly tetanus, so may 
the simple dyspepsia lead to a profound "disturbance of nutri- 
tion" — " alimentary intoxication." 

Diagnosis. — The history, in a way, makes the diagnosis. Im- 
proper feeding, followed by a disturbance, such as we have 
described, almost invariably is " alimentary intoxication." How- 
ever, we have learned from more recent studies not to focus our 
history too carefully upon feeding alone, but to recognize new 
factors, which, by their effect upon the baby's general condition, 
also predispose. To these we referred in dyspepsia, viz., age, 
constitution, infections, poor nursing, and heat. We have 
learned that this condition never develops primarily in a well 
child. There must have been a preceding state of dyspepsia or 
decomposition. The latter we consider in the next lecture. 

The diagnosis is definitely established upon withdrawal of 
food (Fig. 16). 



Days 


: 


L 




j 




5 


4 


\ 


i 




9 lb 
12 oz 
8 oz 
4 oz 
8 lb 
























\ 




















\ 






















\ 




















s 


V 




















\ 




















\ 


v 




















\ 




















\ 


, 



















































Fig. 16. 

If, after twenty-four hours of hunger, {He loss of weight ceases, 
the temperature drops to normal, the diarrhea improves, — the 
latter, however, not being absolutely essential, — we make a 
positive diagnosis of alimentary intoxication. 



218 INFANT FEEDING (CHICAGO METHODS) 

Treatment. — 1. Gentlemen, during the first twenty-four hours 
the child must hunger. During this day the diarrhea and the 
vomiting will empty the intestinal tract of irritants. 

2. Under no circumstances shall we give calomel, castor oil, 
or any other irritating drug. Just think! The intestines are 
acting as rapidly as possible to rid themselves of irritants. They 
are moving just as quickly as they can; you can't make them 
move any more quickly; all that you are doing with these drugs 
is to increase injury. What the intestine needs is not stimula- 
tion: it needs a rest. For this same reason we would not injure 
the stomach and intestines by getting a big pump and repeatedly 
washing out the stomach and flushing out the bowels. Let 
them alone! They will take care of themselves if you give them 
only half a chance. If your aim in using these drugs is intestinal 
asepsis, your hope is in vain! No drug is known which will 
make the intestine sterile. Indeed, animals raised with sterile 
intestinal tracts live only a short time. Barrels of medicine 
haven't nearly the effect of a slight change in diet. 

In addition to the great principle of physiologic rest during 
these twenty-four hours we can aid our little patient in other 
ways: 

3. He is suffering greatly from loss of water: we must supply 
fluids. Give him all the water he wants. 

4. The use of a little salt will aid him in retaining water in his 
body. Simply take a little surgical salt solution — physiological 
salt solution, made by adding a teaspoon of salt to a pint of 
water; dilute this to half -strength, sweeten it with a little sac- 
charine, and offer the baby three to four ounces by mouth during 
the first twenty-four hours. Don't give over this amount, or 
you will produce edema and throw too great a strain upon the 
heart. Edema readily results. 

5. Our little child may need to be stimulated. Under these 
conditions, brandy in doses of 10 to 15 drops every few hours; 
caffein citrate, in doses of 34 grain, may be given by mouth. 
Infinitely more effective is the hypodermic use of 10 to 15 
minims of a 10 percent solution of camphor in oil, repeated, when 
necessary, every few hours. Personalty I have come to place 
more and more confidence in adrenalin. One hears very little 
of this in medical discussions; but, from my own observations, 



THE STATES OF DYSPEPSIA AND INTOXICATION 219 

I am absolutely convinced that in the failing pulse and sinking 
blood-pressure of this condition, just as in surgical shock, hypo- 
dermic injections of two to three minims, repeated every two 
or three hours, are of great value. In my own studies I have 
found that the blood-pressure is raised and maintained for 
periods of one-half hour following injection, probably by the 
gradual absorption resulting from subcutaneous rather than 
intravenous use. 

6. During this first day, treatment of the mother is an impor- 
tant consideration. She, in her maternal anxiety, demands that 
we do something. The substitution of tea for water is a great 
help. From our standpoint, children take it well, like it, and 
we supply fluid to the tissues. We can explain to the mother, 
however, that in tea we have caffein, which is a great stimulant; 
tannic acid, which will tend to combat the diarrhea, and we 
can make the matter more impressive by adding a little sac- 
charine tablet for sweetening. We can busy the mother, during 
the first day, with the general care of the baby, keeping him 
warm, offering with a medicine-dropper small doses of salt 
solution and perhaps a little medicine at regular intervals, but 
under no circumstances shall we diverge radically from our prin- 
ciples. 

7. What medication shall we use for the intestine? Gentle- 
men, if you have understood the principles of this disturbance, 
you see that a little alkali can be reasonable and logical. Chalk 
mixture, with its calcium, can be given in doses of several tea- 
spoons every few hours. It is interesting to see how the older 
men empirically arrived at this remedy; but, gentlemen, under 
no circumstances place your faith in medicine; medicines are 
simply insignificant aids in our treatment, compared to the enor- 
mous influence exerted by food. 

8. While in the stage of simple dyspepsia, ordinary dilution of 
the milk and reduction of carbohydrate suffice for a cure, in 
intoxication we are reduced to the use of two foods only. These 
are breast milk or, if this is not obtainable, "Eiweiss Milch/' 
or albumin milk of Finkelstein and Meyer. 

The principles of this food depend upon ordinary common 
sense. If carbohydrate ferments, it must be reduced. If whey 
so injures the intestine as to enhance fermentation, the whey 



220 INFANT FEEDING (CHICAGO METHODS) 

must be diluted. If casein, by calling forth alkaline intestinal 
juice, by aiding putrefaction, by combining with calcium, over- 
comes fermentation and makes the intestine alkaline, protein 
must be increased. With this object in view Finkelstein and 
Meyer set about making the albumin milk. It was originally 
made as follows: 

(a) To one quart of raw milk add enough ferment to cause 
coagulation and formation of large casein curds. Any milk- 
coagulating ferment will do. In Chicago we use chymogen in 
amounts of one dram to a quart of milk, put up by Armour & 
Co. 

(b) In order to separate the curd from the whey we filter, 
letting the mixture hang in a cloth bag for an hour. During 
this process all the whey drips off and the pure casein curd 
remains. 

(c) This is put through a fine hair sieve, the wire meshes of 
which must be finer than a window-screen. You understand if 
the casein is fed in large pieces it will not exert its physiological 
effects, for only a small amount of it will be exposed to the intes- 
tinal juices and to the bacteria and less calcium can be efficient. 
The center of the curd will be untouched. The success of the 
mixture, then, depends upon a very fine division of the casein. 
It must be put through the sieve two or three times. 

(d) To the finely divided curd we add one pint of buttermilk. 
Buttermilk supplies salts, and a baby must have salts to live. 
You ask why a pint of whole milk or skimmed milk will not 
suffice. Whole milk, you remember, contains fat, which we are 
glad to reduce in these severe cases. Whole milk and skimmed 
milk both contain lactose, which is very fermentable. Butter- 
milk not only has no fat, but also has very little lactose, and 
possibly even the lactic acid may be of aid. 

(e) Enough water is added to make one quart. The mixture 
is boiled, stirred with a cutting motion to prevent the reforma- 
tion of large curds, and divided into bottles. Upon offering 
them to the baby, these bottles must not be heated above body 
temperature or large curds again will form. You see now what 
this mixture contains: 

(a) The casein of one quart of milk plus that of one pint of 
buttermilk. 



THE STATES OF DYSPEPSIA AND INTOXICATION 221 

(6) The whey of one pint of buttermilk; thus the whey has 
been reduced to one-half. 

(c) Almost no lactose. 

Everything in this mixture speaks for alkali formation — 
speaks against acid formation. What a curious world! In the 
olden times we threw away the curd and used the whey; now 
we throw aWay the whey and use the curd. This mixture is 
ideal to overcome the fermentative stool, to neutralize the intes- 
tinal reaction, and to stop the diarrhea. Shall we feed this 
mixture to the baby? What an ideal mixture this is to kill our 
little patient! You look surprised. You have made just the 
same mistake as Finkelstein and his assistants. Reports of pro- 
test came rapidly from all over the world. Not long, however, 
before the error was detected. Finkelstein and Meyer had made 
the same mistake that we have seen repeated time and time 
again. They focused too carefully upon the stool and forgot the 
baby! True enough, the intestinal condition was cured; the 
stools became alkaline and constipated, but the baby died! 
Gentlemen, the baby died from lack of carbohydrate! In our 
intense desire to treat the diarrhea we forgot the baby. The child 
must have carbohydrate to live, and this baby was getting an 
amount insufficient for life. Without going too much into detail, 
it was learned that in albumin milk it is perfectly safe to give 
at least 3 percent carbohydrate. If this is given in the form of 
non-fermentable carbohydrate, such as dextrin-maltose prepar- 
ations, no harm will result ; so in making albumin milk, never 
commit the fatal error of omitting 3 percent carbohydrate. In 
offering albumin milk, instruct the mother to use a nipple with 
a large hole, as some of the casein curds may stick in a small one. 
You may also add a little saccharine for sweetening, for when 
the child gets stronger, he may object to the taste of the butter- 
milk. 

In offering the baby breast milk or albumin milk, shall we 
give a full bottle? Gentlemen, to do so means death. Even if 
a wet-nurse be obtainable, if we, thinking that breast milk is an 
ideal food, recklessly allow the child to nurse, we probably shall 
lose him in a few hours. With such an intense degree of fermen- 
tation existing in the intestine, the large amount of sugar in 



222 



INFANT FEEDING (CHICAGO METHODS) 



breast milk, even though it be in the healing breast-milk whey, 
may ferment and increase the damage. 

In all cases our technic must be extremely rigid and exact. 

1. Keeping up the same general treatment of the first day, 
stimulation and fluids in the form of tea, we offer ten feedings 
of about Y2 ounce each of food. 

2. The next day we increase to ten feedings of % ounce. 

3. The following day we may increase to ten feedings of 
1 ounce, then to 1% or \y 2 ounces. Here we wait and note the 
reaction of our weight curve (Fig. 17) : 





\ 




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? 


, 


1 




5 


e 




7 




"If 




) 


■ 1 





u 




12 


1 


3 


1 


4 


9 Vb 
12 oz 
8 02 
4 oz 
8 1* 
12 oz 
8 02 

4 02 

7 1* 




























































\ 
























































\ 










































































































































-SI 
























/ 




















< 




-Si 

Cvl 




<-i 




l-i 




CM 
















f 


^ 






















X 




X 




X 




X 




X 














s 


/ 




















s 








H 




r-1 




r-i 




H 




























































































\ 
























































\ 






^ 


























































"N 


•< 


























































^ 




























































^ 




-SSJ 




"* 




■*■ 




^ 




& 




























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,_, 




^ 




H 












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X 




X 




V 




X 




X 




X 




X 




X 




M 




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H 




n 




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1-1 




c 




O 


































































Fig. 17. 

We hold the food perfectly constant at 10 x 13^, independent 
of the stools, until the weight curve has straightened out. If 
the weight curve still sinks; if the diarrhea continues, undei 
no circumstances make any change in the food. The danger of 
a change is greater than the danger of leaving it as it is. When, 
however, the weight curve has become horizontal, we continue 
to increase gradually to the maximum quantity; that is, about 
three ounces of the mixture for every pound of the baby's weight. 
Then we cautiously increase the carbohydrate to 5 percent. 
After a few weeks we return to an ordinary milk mixture. It 



THE STATES OF DYSPEPSIA AND INTOXICATION 223 

is not good policy at any time to make any change while the baby 
is gaining. 

I have gone into such detail, gentlemen, not because I want 
you to remember the technic exactly of making albumin milk, 
but because I want you to remember the principles. If you 
have these principles, then, no matter where you are or what 
means are at your disposal, simply make up a combination of 
high protein, low whey, and non-fermentable carbohydrate. 
Never commence with large doses, but, following a hunger 
period, guided by your weight curve, offer gradually increasing 
amounts. 

These principles you can apply to your older children — chil- 
dren of one to three years of age : 

1. Hunger with tea and fluids for the first day. 

2. Reduce the whey by removing milk or diluting it to one- 
third or one-half. 

3. Increase the protein by giving egg, scraped meat, cottage 
cheese, and curds of milk. 

4. Give non-fermentable carbohydrates, zwieback, mashed 
potato and cereals, such as corn-starch, Cream of Wheat, and 
arrowroot. 

5. Supply salts best as vegetable purees. 

Don't forget the hunger period ; don't forget fluids, and, above 
all things, in the beginning of the treatment, don't forget the 
tiny doses of food. 

Gentlemen, if you are thoroughly conversant with these 
principles, no matter where you are, no matter how primitive 
the home, you will always be completely master of the situation. 



LECTURE VI 
DECOMPOSITION 

Gentlemen, in the previous lectures we discussed three types 
of nutritional disturbance. You remember it was Finkelstein 
who, for the first time, clearly and emphatically laid importance 
upon factors of nutrition and food, in the production of what we 
previously had called "the diarrheal diseases of infants." That 
many of his first explanations were incomplete; that many of 
his views again will be amplified, there can be no doubt. But 
his service has been immeasurable. In the lectures on dis- 
turbed balance, dyspepsia, and intoxication we described the 
clinical pictures as he saw them. Today we concern ourselves 
with the last of the four, the subject of decomposition. You 
gentlemen have known this condition as atrophy, marasmus, 
or malnutrition. It is familiar to you all. Finkelstein, however, 
did not think that these terms described accurately the compli- 
cated processes being evolved in the child's body, and so sug- 
gested a term of his own. Names, of course, are immaterial. 
If you prefer the older terms, well and good. The essential, 
however, is that you understand the changes taking place in 
the child. There, is an actual disintegration of body substance. 
Finkelstein thought the usual terms misleading and so spoke of 
decomposition, which in German means destruction. 

It is hardly necessary to describe the picture. Doubtless you 
have seen it often. A tiny, undernourished infant, weight far 
below normal, lies restless and crying in his bed or in his mother's 
arms. Simultaneously one notices the pallid, blue, wrinkled, 
tissue-paper-like, fat-free skin, and the whole bony skeleton that 
seems to protrude through it. The face is that of a tired old 
man. The large, deep-seated eyes move restlessly about, then 
fix upon you with an uncanny stare. The large mouth, with its 
thin lips opened wide in a never-ceasing fretful cry, is in striking 
disproportion to the small, weazened face, or is hidden com- 

224 



DECOMPOSITION 



225 



pletely by the fists which the child chews greedily in a vain 
attempt to relieve his pitiful hunger. The peevish tones reveal 
perpetual misery. The emaciated skin of the thorax reveals the 
bony framework in all its detail, and the thin covering of the 
abdomen cannot conceal the outlines and movements of the 




Fig. 18. 




Fig. 19 



viscera. On the extremities the skin hangs in large folds right 
over the bones (Figs. 18 and 19). 

In sharp contrast to intoxication, consciousness is undis- 
turbed. If anything, it is excited. You remember how the 
child with intoxication lies drowsily, eyes fixed apathetically on 
15 



226 INFANT FEEDING (CHICAGO METHODS) 

one corner of the room, arouses himself with a short cry, and 
again lapses into semi-consciousness. This child is on the alert, 
cries pitifully, incessantly, and never seems to sleep. You 
remember the child with the intoxication had rapid, tireless 
respiration. This child has the slow, feeble, irregular type. 
In intoxication the pulse is rapid. In decomposition the pulse 
is slow and weak. Normally in an infant the pulse ranges around 
120. Here it may be 80 or below. In intoxication the temper- 
ature usually is elevated. In decomposition it is subnormal — 
the more subnormal, the worse the disturbance. In contrast 
to the albuminuria, glycosuria, and casts of intoxication, the 
urine of this child is negative. Intoxication suggests acute 
poisoning; decomposition, chronic collapse. 

Symptoms from the gastro-intestinal tract vary with the food. 
Vomiting is not unusual. Stools, however, depend to a large 
extent upon the diet. When this is large, particularly if high 
in carbohydrate, intestinal fermentation becomes active, with 
resulting diarrhea. This is very easy to understand when we 
consider that the intestinal tract suffers in its general nutrition 
as much as does every other organ of the body. It is perfectly 
rational, then, to assume that the functionally injured intes- 
tinal cells of the upper digestive tract do not suppress bacterial 
growth as they do in the normal infant. Consequently any 
improper combination of food, especially mixtures rich in whey 
and carbohydrate, stir these bacteria to growth, and in the 
resulting fermentation are formed the irritating acid products 
which lead to dyspepsia and intoxication. In such a condition, 
if much fat is fed, it will be carried out in the stool. We do 
not mean to be too dogmatic. It is perfectly reasonable and 
logical, and there is also good evidence to show that the digestive 
ferments are not very active, and we can readily understand the 
appearance of fat in the stools, due to its improper digestion 
and assimilation. We believe, however, that in the majority 
of cases fat appears passively, being secondary to the primary 
fermentation of the carbohydrate. 

On the other hand, if the restricted diet is high in protein, 
low in carbohydrate and whey, the stool becomes alkaline and 
hard. Now less undigested fat appears. This observation again 
supports the premise that fat is really the secondary factor. 



DECOMPOSITION 227 

Again, the smaller the diet, the less likely will the stool be diarrheal. 
Perhaps no better illustration can be afforded of the danger of 
being guided in treatment by the condition of the stools. Many 
of these babies go down and die in collapse, with typical consti- 
pation. No greater or more terrible mistake can be made than 
of focusing all one's attention upon the character of the stool 
(treating the stool so as to change it from a diarrheal to a con- 
stipated type) and forgetting the baby in the meantime : allow- 
ing the baby to go down and die in the collapse of hunger. This 
danger can be avoided if one remembers what we have repeated 
again and again, that the stools are simply indications of 
what has been put into the intestinal tract, of the way that food 
has been handled, and are only a tiny guide to us — simply a 
symptom of scarcely more importance as an absolute indication 
for therapy than is the condition of the skin, than the condition 
of the baby's heart and pulse, than the condition of the baby's 
breathing. They constitute simply one of the many important 
symptoms of the condition. As the weakened pulse points to 
the failing circulation, so do the abnormal stools point to an 
inefficient digestive tract. This latter — not the stool — is one of 
the objects of our therapy. 

In these conditions we have dwelt upon the fundamental 
importance of the weight curve and the food reactions (Fig. 20). 

If at A, the child being in a state of decomposition, and hav- 
ing lost weight for months, we give a bottle adapted to a normal 
child, he loses steadily three to five ounces a day, and dies not 
infrequently with symptoms of intoxication. On the other 
hand, withdrawal of food for twenty-four hours produces a sharp 
drop in weight, the child dying in acute collapse. 

Gentlemen, no more terrible mistakes are made than allowing 
children in this condition to hunger. They are so susceptible 
to all influences that a period of hunger of twenty-four hours, 
which scarcely would be noticed by a normal baby other than 
by his loud protests, results in rapid death. 

In addition to the above clinical symptoms the child shows 
great change in reactions to external influences. He is particu- 
larly susceptible to heat and to cold. He is susceptible to all 
forms of violence, readily injured by improper nursing and care, 
particularly likely to be attacked and carried away by the infec- 



228 



INFANT FEEDING (CHICAGO METHODS) 



tious diseases. Ludwig F. Meyer says aptly that these children 
sicken from causes of nutrition and die from infection. Fatal 
infections frequently are overlooked, even by the most experi- 
enced, because the child is so weakened in his reactions that the 
most virulent infections may give no clinical signs. The baby 
is too weak to react with temperature, too weak to show acceler- 
ation of the pulse or of the breathing, and only postmortem 
examination reveals how frequently our little patients have been 
carried away with terminal pneumonias. 



Months. 






1 




j 






i 




i 


i 






i 


i 


\ 


Da 


y. 








5 




r 


12 lbe, 

11 

10 

9 

6 

7 

6 

5 lbs, 
























i 












































































\ 


















































\ 


















































\ 


V 
















































s 


V 
















































v 


\ 


















































\ 


















































\ 


















































\ 










































































































































































































































































































\ 


/ 














































H 


- 














~4 


• 



















































Fig. 20. 



Often we find masked types of decomposition. Upon hasty 
clinical examination, we may think our little patient is only in 
a state of dyspepsia or disturbed balance. We become suspi- 
cious, however, on learning of a previously irregular weight 
curve, and noting deficiency of fat in the subcutaneous tissues 
and skin of muddy color. Our opinion will be confirmed when, 
upon treating this child for a dyspepsia, withdrawal of food pro- 
duces not the usual slight reaction of the weight curve, but a 



DECOMPOSITION 



229 



sharp, severe drop of many ounces, associated with subnormal 
temperature (Fig. 21). 



Days. 




. 




» 




I 


4 


[ 


10 lb. 

12 02, 

8 

4 

9 lb. 


100 
99 
98 
97 
96 




































































k j>-- - 


>i 
















\ 


















v > 


k. 


\ 
















\ 





































Fig. 21. 

Gentlemen, whenever you find a child upon withdrawal of 
food reacting with symptoms of collapse and subnormal tem- 
perature, no matter how slight you considered the disturbance, 
beware of one of these masked types of decomposition. Remem- 
ber that that child is particularly susceptible to external influ- 
ences — to hunger, to heat, to cold, to infections, to poor nurs- 
ing, to improper food — and look upon him as a very sick baby. 

Metabolism. — Having studied the clinical picture carefully, 
we now must investigate the causes. Don't misunderstand me, 
gentlemen ; it has long been known that this picture can be pro- 
duced by -tuberculosis, syphilis, wasting diseases, and other con- 
ditions; but it remained for Finkelstein to show that a great, 
great number of these cases — cases in which the etiology pre- 
viously had been mysterious or unknown — was based upon and 
resulted from the same fundamental errors in nutrition of which 
we have spoken so frequently. For the first time we see in 
careful clinical examination, this condition also studied from the 
broad viewpoint of nutritional disease. Such a child, when 
placed upon a metabolism bed, shows a sharp contrast to dys- 
pepsia or disturbed balance, for he suffers actual loss of protein 
from the body, the body losing more protein than is taken in. 



230 INFANT FEEDING (CHICAGO METHODS) 

The same holds true for mineral matter ; more salts are lost than 
are contained in the food. Indeed, much of the clinical picture 
maybe simulated by mineral hunger. Such investigations are 
very difficult, are few in number, but are of tremendous value. 
It was due to this conception, to this idea, that actual destruc- 
tion was taking place that Finkelstein changed the term from 
atrophy to decomposition. 

The fat metabolism depends upon the way fat is administered. 
If it is given in a mixture rich in carbohydrate and whey, the 
fat is lost in the resulting diarrhea. If a reasonable quantitj^ is 
given in a mixture high in protein, low in carbohydrate and whey, 
the fat is well assimilated. 

As regards carbohydrates, the body itself seems to need and 
use them well. The great difficulty, however, is to get them 
into the body, for with the weakened condition of the upper 
intestine permitting bacteria to flourish, carbohydrates, unless 
given very carefully, are apt to ferment and cause diarrhea, with 
pictures varying from the slightest dyspepsia to the severest 
intoxication. 

Diagnosis. — The diagnosis is easy. A freshman medical 
student, a novice, a beginner, can recognize such a picture at a 
glance. It makes absolutely no difference what name we give, 
the clinical picture is there ; and it remains for us as medical men 
not to be content with a mere diagnosis, but to insist upon a 
diagnosis of the cause. We have spoken of tuberculosis, syphilis, 
and wasting disease ; these are well known ; but of new factors 
from the viewpoint of nutrition we are learning more and more. 

1. We have learned that this condition never comes in the 
midst of health. The child must have been sick for weeks or 
months, with a history of ailing, of digestive disturbance, and 
of not thriving. 

2. We have learned the importance of age. The younger the 
child, the more susceptible he is. 

3. We have learned the importance of diarrheas, not only 
those from improper feeding, the dyspepsias, but also those 
resulting from true pathogenic bacterial infection. In each of 
these attacks the child probably loses a little mineral matter, 
and if the diarrhea is not handled properly, the loss eventually 
may be so great as to bring on decomposition. 



DECOMPOSITION 



231 



4. We have learned that long-continued undernourishment 
is an important factor, the baby not getting for a sufficient time 
a great enough total quantity of food. 

5. Hunger is a tremendous factor, particularly hunger applied 
too long to a sick child (Fig.. 22) . 



TtayR 




1 




2 




3 




\ 




9 lb 
12 or 

8 oz 

4 02 

8 lb 






















\ 


















\ 




















\ 


















\ 






B 












* 


l 




\ 


















\ 




















\ 


















\ 











































Fig. 22. 



You remember in intoxication when the weight curve was drop- 
ping rapidly, if we removed food at A for twenty-four hours 
the drop of weight ceased and the curve straightened out. If 
at the end of twenty-four hours, at B we had not started to 
feed that baby perfectly independent of the number or condition 
or appearance of the stools, if instead of feeding him we had 
prolonged the hunger period, guided only by the condition of 
the stools, the weight curve would have swung down, taken 
another sharp drop, and we would have been responsible for the 
additional calamity of decomposition. 

6. Important as is absolute hunger, partial hunger is perhaps 
even a more frequent cause. By partial hunger I mean one- 
sided feeding, such as feeding with barley water or condensed 
milk. Due to the fault of the physician or the carelessness of 
the mother, children are kept for days on a diet of barley water. 
This, as you know, is largely carbohydrate, and after four, five, 
or six days, the child suffering in the meantime from insufficiency 



232 INFANT FEEDING (CHICAGO METHODS) 

of protein, salts, and fat, decomposition develops. This type 
was the one that Czerny described as starch injury. Condensed 
milk perhaps is the most frequent cause. It is very high in sugar, 
low in other elements, as protein and salts. You remember in 
our second lecture we spoke about the property of sugar to bind 
water in the tissues. Due to the high sugar of condensed milk, 
a great deal of water is retained in the tissues of these children. 
They gain for some weeks, and the doctor and mother are 
delighted, because they think the baby is doing so well. As a 
matter of fact, however, the baby is starving, his tissues are 
being filled with water, and his body-cells are dying from lack 
of protein and salt. Only the severe reaction following a slight 
infection, following a little exposure to heat or a slight error in 
diet (such as feeding a little too much or letting him hunger 
too long), shows that we are handling a child who really is in 
the stage of decomposition. Too long exclusive feeding with 
breast milk belongs to this class. This sounds like heresy, gen- 
tlemen ; but nevertheless it is true. This is no infrequent factor. 
As you remember, breast milk is very low in protein and very 
low in mineral matter. After a child is nine months or more 
of age the demands of his body are greater than those answered 
by the breast. Kept too long exclusively upon this food, with- 
out the addition of other substances to cover these wants, or 
without an enormous supply of breast milk, the body-cells suffer 
from lack of protein and salts, and the child gradually develops 
decomposition. 

7. The most frequent factor of all is probably the fault of the 
physician, the one for which you largely are to blame, — I don't 
mean you personally; I mean you, me, all physicians, — namely, 
the improper treatment of mild dyspepsias. The development 
is as follows: The child gets a slight dyspepsia; the physician, 
not recognizing the food nature of the disturbance, cleans him 
out with calomel and castor oil; gives him a little paregoric to 
check the bowels, and makes no change in the food. Repetition 
occurs in perhaps two or three weeks. Again the child is cleaned 
out, again is he subjected to the irritating effect of calomel, and 
again the bowels are drugged with paregoric; but the food is 
unchanged. Maybe the factor of hunger is introduced. A 
recurrence of diarrhea leads to the same treatment. Now the 



DECOMPOSITION 233 

physician says: "We certainly will give these bowels a rest. 
We are going to let this baby hunger a good long time." No 
factor, gentlemen, is more important in bringing these children 
to this condition than is the frequent combination of improper 
therapy of dyspepsia plus the improper use of hunger. Remem- 
ber, gentlemen, the longer the hunger, the greater the danger. 
Remember, the more frequently repeated the hunger, the greater 
the danger; and remember, the closer together the hunger 
periods, the greater the danger. This combination of improper 
treatment of dyspepsia plus the improper use of hunger periods 
is the most important of all the nutritional factors in producing 
decomposition. 

Besides the above errors in nutritional technic, we must never 
forget that the same influences are effective that were concerned 
in the production of dyspepsia and intoxication, influences which 
are independent of our skill, and for which we are not to blame; 
namely, constitution, infection, and improper care. A baby 
with a weak constitution, a baby who repeatedly has had infec- 
tions, a baby who is improperly cared for, is far more susceptible 
to a nutritional error than is a healthy strong child. 

Treatment. — Gentlemen, let me urge upon you that the most 
important treatment by far is prophylaxis. If we handle dys- 
pepsias properly; if we realize the importance of the state of 
disturbed balance; if we see that the well baby is properly 
nursed and cared for, properly dressed and properly fed, the 
number of cases of decomposition arising from nutritional 
sources will be very few indeed. 

Once developed, however, the condition is difficult to treat, 
and requires careful, definite routine. Only upon two foods can 
we rely. Just as in intoxication, we have absolute confidence 
only in breast milk or albumin milk. 

During the first day, if a bad diarrhea is present, the child 
may hunger six, to at the very most twelve, hours; never under 
any circumstances longer. Preferably, he should miss only one 
or two bottles, and none if the stools are few in number. During 
this period the general treatment is that of intoxication; that 
is, the use of stimulants, the use of water and tea, the use of a 
little salt. 

Following the hunger period, or if no diarrhea be present at 



234 



INFANT FEEDING (CHICAGO METHODS) 



once, we start food. The first day we offer ten feedings, with a 
total in twenty-four hours of ten ounces. Gradually we increase, 
adding two to three ounces to the twenty-four-hour total every 
other day. Our maximum with albumin milk is three ounces 
for each pound of body weight; that is, a baby weighing seven 
pounds shall get a total of 21 ounces, a baby of nine pounds a 
total of 27 ounces. During this increase our guide is solely the 
weight curve. Gentlemen, let me impress upon you that no 
graver mistakes can be made than letting the condition of the 
stools influence your treatment. We are interested in saving 
the baby. The baby is infinitely more important than his 
gastro-intestinal canal. If to save the baby it becomes neces- 
sary to neglect all symptoms of impaired digestion, we must do 
so. The gastro-intestinal tract is simply a means of introducing 
nourishment. We absolutely must give food. If we let this one 
symptom, the stool, sway us from our course, though we correct 
the condition of the stool, we frequently lose our patient. Our 
guide to increase shall be the weight curve. To illustrate (Fig. 23) : 



Weeks 




. 




: 


: 


\ 


. 


> 


■ 




Da 


ys 


2 




'. 






\ 






< 






1 


10 lb 
12 o: 

8 02 
4 OS 

9 It 

12 02 
8 02 

4 o: 
8 11) 

12 oj 
























































































































































































































M 
















































O 


























































































































































J 


\ 




































A 




*"*■ 


"-« 


*> 






















































^ 


















































! 


■ 











Fig. 23. 



The baby has been sick for weeks, the curve constantly com- 
ing downward. At A he is in the state of decomposition. We 
allow him to hunger or offer small quantities of food, a total in 
twenty-four hours of ten ounces. Due to the hunger or due to 
the small quantities of food he continues to lose slightly. We 



DECOMPOSITION 235 

make no change until at B his curve has straightened out. A 
continuation downward at C shows that the destructive process 
is continuing; under these circumstances we are in no condition 
to increase the diet, nor to change nor to withdraw it. If we wish 
to save the baby, we must hold the quantity constant and steady, 
independent of the stools, until the curve has straightened and 
shown that destruction is ceasing and that the baby now is in a 
position to assimilate nourishment. This is the time to start 
a gradual, cautious increase according to the schedule just given. 
If the baby is breast fed, under no circumstances put him to the 
breast the first few days. The mother must express the milk 
from her breasts and give these quantities exactly from a bottle 
or medicine-dropper. When the curve finally has straightened 
out, — a matter of a few days, — we sigh with relief, for the battle 
is won; and now, after the child has gained slightly, it is safe 
to put him again gradually to the breast. 

In the last lecture I gave in detail the technic of making albu- 
min milk. I wanted you to know the original process, so as to 
emphasize the principles of the mixture. You remember they 
were low whey and low carbohydrate to reduce the factors caus- 
ing fermentation; high protein to increase the factors causing 
alkalinity and overcoming fermentation. Today I want to give 
you a simpler technic quoted by Langstein and Meyer, one 
which you may use in the humble home, where ignorance of the 
mother or lack of facilities renders impossible the more compli- 
cated mixture. 

One takes one quart of buttermilk and one quart of water, 
mixes them well, lets them boil a few minutes, and allows them 
to stand for at least half an hour. During this period the casein 
curd settles to the bottom and the clear whey-water mixture 
rises to the top. You see, by the addition of water we have 
diluted the whey one-half. Without disturbing the casein curd 
lying below, we pour into another jar as much whey as possible. 
This separates curd from whey. In this process we boiled the 
milk. In the original we used it raw. If we had boiled it in the 
original technic the curds would have been too fine to be separated 
from the whey, being able to pass during the filtration through 
the meshes of the muslin bag. To the casein curd we add four 
ounces of boiled cream. This is done because in the original 



236 



INFANT FEEDING (CHICAGO METHODS) 



mixture, during precipitation of the casein, considerable fat is 
ensnared in its meshes, the fat content of albumin milk be- 
ing 2 to 3 percent. Accordingly, we add cream to this mixture. 
We then add the usual 3 percent of a dextrin-maltose. Not 
having "dextri-maltose," we can use foods of somewhat similar 
nature, such as Mellin's Food or Horlick's Malt Food. Our 
mixture now contains high protein, a certain amount of fat, a 
certain amount of carbohydrate in a non-fermentable form, and 
to add salts we fill up to a total of one quart with the original 
water-whey mixture in our second jar. You see in this process 
we have reduced the whey to one-half. In cases where the child 
does not take albumin milk well it can be sweetened with a 
little saccharine. 

And now, gentlemen, before concluding, let me call your 
attention to a most fascinating study, one to which this treat- 
ment with albumin milk has directed us (Fig. 24). 















; 


{ 












D 


»y s 








5 




■ 




> 




> 




r 




J 




) 


10 lb 

6 oz 
9 lb 

8 02 
8 lb 






































































































































































/ 




























































/ 
























































































































































































































I 
























" 






. 


A 
















































s 








Y ' 










































3 


of 


» 




7[oA> 




9 


o/ 


a 
















































1 1 

















Fig. 24. 



At A the weight curve has straightened out, the destructive 
process has ceased, the battle has been won, and the child is 
getting the total prescribed amount of albumin milk, but he 
is not gaining. We are giving the maximum quantity, namely, 
three ounces for each pound of body weight, but the weight 
curve is stationary. Here a very interesting study commences. 
Our first idea that sugar alone is dangerous and harmful makes 
us very careful about increasing the carbohydrate. We cau- 
tiously increase to 5 percent. In some cases the weight curve 
makes a sharp ascent; in others it remains stationary. After 



DECOMPOSITION 



237 



a few days, in the latter case, we feel our way again and increase 
to 7 percent. Usually the curve takes a sharp rise and the im- 
provement continues, but it may remain absolutely horizontal. 
Again, with extreme care, and under no circumstances if the curve 
shows a tendency to fall, we increase to 9 percent, and almost 
invariably with 9 percent the child will gain. With 7 percent 
or 9 percent the stools may become dyspeptic, but employing 
albumin milk, we overlook them. Under no circumstances use 
such high carbohydrate with any food other than albumin milk. 




Fig. 25. 



Here is the baby we just showed as a case of severe decompo- 
sition. He entered our hospital wards aged four months and 
weighing six pounds. On albumin milk with 3 percent dextri- 
maltose he showed no reaction for three days. An increase to 
5 percent resulted in no further gain. Three days later, however, 
a further increase to 7 percent was followed by a rapid increase 
in weight and marked improvement in his general condition. 
This photograph, taken at the age of five months, just four weeks 
later, shows him weighing nine pounds four ounces. Just com- 
pare this to his previous condition, and you will notice the rapid 
response to high carbohydrate feeding, a gain of 3 pounds 4 
ounces in a month (Figs. 18, 19, 25). 

This interesting clinical study gives an insight into some of 



238 INFANT FEEDING (CHICAGO METHODS) 

the processes taking place in the child's body. It shows that 
this child, to thrive, needs more carbohydrate than does a nor- 
mal one ; and when we stop to think, this is not unreasonable, 
because he is so handicapped that he probably needs more energy 
than does the healthy baby to carry him along. Our problem 
has become clear. We must convey food to this child's tissues. 
In some cases the deficiency is one of protein and mineral matter. 
In the majority, however, high carbohydrate also must be con- 
veyed. We have before us the problem of sending high carbo- 
hydrate into the baby's body; of getting it through the intes- 
tinal wall before the hungering bacteria lying in wait in the 
intestine, can ferment it to the irritating acid products; with- 
out its carrying the patient to death from intoxication before it 
reaches the body-cells craving it. Albumin milk has solved this 
problem in a mysterious, unexplainable way. It was never 
devised for this purpose, but it is just as effective, nevertheless. 
If we feed a child with decomposition a concentrated milk mix- 
ture containing high carbohydrate, he rapidly develops the 
severest intoxication. Whether the child's demands are abso- 
lutely specific for carbohydrate or simply for more energy may 
be open to argument. But even if the latter is true, carbohy- 
drate becomes the most convenient means of supplying the 
needed energy. With albumin milk we can feed carbohydrate 
with relatively slight danger of intestinal complication. 

How albumin milk does this is unknown. We have much to 
learn, and perhaps some one will explain it; but it is a fact, 
nevertheless, that albumin milk has become a vehicle for intro- 
ducing carbohydrate into the baby's system. 

The treatment with albumin milk should last four to six 
weeks, and then the baby is put upon an ordinary milk mixture. 
For a few days the stools will be somewhat loose; these can be 
disregarded. If the baby has been breast fed, although he 
seems subjectively better, gain in weight may be very slow in- 
deed. This period the older men have called the "reparation 
period," offering the explanation that during these weeks the 
child's tissues were reorganized. This failure to gain we now 
believe due to tissue hunger. Breast milk you know is low in 
salts and in protein. The ideal food for a normal baby, it is 
not a mixture ideal for an infant to recover severe losses of these 



DECOMPOSITION 239 

elements. The addition to the breast milk of small quantities 
of a buttermilk mixture sometimes works wonders. This com- 
bination is rich in protein, rich in mineral matter — the very 
substances in which breast milk is deficient. If given in quan- 
tities of one-third to one-half of the total amount of breast milk, 
the child may gain at a much earlier date and the so-called 
reparation period be avoided. 

Having mastered these processes, we are in a position to treat 
decomposition in an older child. Always hold before you the 
picture of the technic with albumin milk. In the older child 
also, the period of hunger, if diarrhea is present, must be short, 
and then we start to feed. How shall we make up our diet? 
First, we reduce the whey as much as possible, the whey being 
the element that seems to aid fermentation and the formation of 
irritating acids. This means that we either can remove the milk 
entirely from the diet or, preferably, dilute it to one-third or 
one-half strength. To offer the child food which will alkalinize 
the bowel and overcome fermentative processes we feed high 
protein, namely, scraped meat, eggs, cottage cheese, or even 
ordinary curds of milk. Custards are taken well and provide 
an easy method of offering eggs. To supply carbohydrate in 
non-fermentable form we use cereals, such as corn-starch, farina, 
Cream of Wheat, arrowroot, and well-boiled rice. We don't 
advise oatmeal, because in some cases this seems to ferment 
easily. Other non-fermenting carbohydrates are mashed Irish 
potatoes and the doubly baked bread, known usually under the 
name of " zwieback." Now we have a combination high in 
protein, low in whey, containing non-fermentable carbohydrates, 
low only in salts. These we supply in broths and soups and by 
vegetables ground through a very fine sieve in the form of 
purees; we supply a mixture high in protein and in salts by 
offering a small quantity of buttermilk; but remember the but- 
termilk contains all the whey elements, hence tends to aid fer- 
mentation, and therefore should be used in small quantities and 
handled carefully. 

Remember, gentlemen, that the technic we use, however, 
must be identical to that employed with a little baby. Hunger 
periods are short; the quantity of food, at first small, is grad- 
ually increased, and above everything else the guide to the quan- 



240 INFANT FEEDING (CHICAGO METHODS) 

tity of food must be the weight curve, rather than the condition 
of the stools. 

The general treatment must be that of intoxication, with 
particular emphasis upon the protection of the child from all 
dangerous external influences. He must be well cared for, pro- 
tected from infections, and guarded from extremes of heat and 
cold. 

Our hour is now up. I have tried to impress you with the 
importance of looking upon these children as children in whom 
the entire nutrition is changed. In treating such a baby, under 
no circumstances let the condition of the stool control you. 
The stools are only symptoms of the condition of the gastro- 
intestinal tract. The gastro-intestinal tract is simply a means 
of your introducing proper elements of food into the baby. If 
you decide that a child needs carbohydrate, then you must give 
it. Even though the digestive tract rebel; even though diar- 
rheal stools point to fermentation, don't lose your courage pro- 
vided the weight curve does not begin to sink. In the latter 
case, under no circumstances totally withdraw the carbohy- 
drate. Humor the digestive tract. Change your food combi- 
nation. Give your carbohydrate in the combinations in which 
it will be relatively harmless, such as breast milk or albumin 
milk, but don't give up your principles. With a little com- 
promise, a little shifting of technic, a wise general can make 
the digestive tract his obedient servant. Never under any cir- 
cumstances let it become your master. 

Question (by Dr. Flippen, Pilot Mountain): Doctor, in the 
treatment of your older children the diet seems to be much the 
same, both in intoxication and in decomposition. If the treat- 
ment is the same, what can be the difference in the two condi- 
tions? 

Afiswer— -Intoxication is an acute affair, the symptomatology 
being induced perhaps by the very rapid loss of water from the 
body. Intestinal fermentation induced by any cause is the 
primary factor. Decomposition is a chronic condition, lasting 
for weeks or even months, the symptomatology being induced by 
destruction of body tissue from various causes. There is a 
gradual loss of protein and mineral matter from the tissues, the 



DECOMPOSITION 241 

intestine suffers secondarily, and thus fermentative processes are 
easily established. 

Our treatment in intoxication is primarily to allow the intes- 
tine to rid itself of irritants, and then to give a feeding which will 
overcome the fermentative processes. 

In decomposition we recognize the extreme need of the body 
for food, but we recognize also the liability of this food to fer- 
ment in the intestine; thus, in giving food we must give it just 
as we would in intoxication, in non-fermentable form. We 
might say that this form of treatment from an intestinal stand- 
point is an active treatment in intoxication and a prophylactic 
one in decomposition. 

This is a good time to pause and to consider for a moment the 
significance of the entire four groups of cases: disturbed balance, 
dyspepsia, intoxication, and decomposition. Don't make the mis- 
take of so many and think this was Finkelstein' 's entire classifica- 
tion. Like Czerny, Finkelstein recognized intestinal disturbances 
due to many different factors. His great service, however, was to 
teach us the importance of food, and to demonstrate four clinical 
pictures with characteristic weight curves, in which food played an 
important part. In some of these, primary fermentation of sugar 
featured prominently in the etiology and symptomatology. To speak 
of the entire group, however, as a fermentative group does not give us 
a broad enough conception; for in some, putrefaction predominates; 
in others, intestinal fermentation while causing much of the symp- 
tomatology, is secondary to influences besides those of food; and in 
the largest group, the symptoms are brought about not by fermenta- 
tion alone, but by fermentation plus a great variety of other factors. 
These are not exclusively intestinal affairs, but are true distur- 
bances of nutrition. The Middle West has, from the beginning, 
taken to these ideas readily, and like Finklestein we believe that 
this conception of disturbance of nutrition is a valuable aid in 
the therapy of the majority of those cases usually described as the 

GASTRO-INTESTINAL DISEASES OF INFANCY. 



16 



LECTURE VH 
PARENTERAL AND ENTERAL INFECTIONS 

Gentlemen, we now have finished Finkelstein's original classi- 
fication. You remember that pathology, bacteriology, and 
etiology failed us, and for the present we decided clinical obser- 
vation to be safest. Do not for a moment think that the last 
word has been said. We are learning every day. New factors 
are being added, old ideas changed; but if we keep the clinical 
picture constantly before us, we shall not go far astray. To 
show what the clinical viewpoint has accomplished, let me re- 
mind you of the modification of Czerny's idea of "milk injury" 
effected by clinical studies. Bedside observation and reasoning 
added the factors of improper care, nursing, post-infection, and 
insufficient sugar. In the same way I wish to show this morn* 
ing how careful observation has increased our knowledge of 
dyspepsia. 

The original viewpoint of Finkelstein was that all cases of 
dyspepsia were due to sugar. Later this was modified to sugar 
and whey. For a moment he was side-tracked, concentrating 
too exclusively on the one symptom — the acid watery stool ; but 
clinical observation and thought saved the day. To illustrate: 

1. In his institution ten babies lie in each ward. Frequently 
after thriving for three or four weeks every baby in a certain 
ward developed diarrhea. Had we focused our attention ex- 
clusively upon the stools, we probably would have observed a 
few curds of fat, a little mucus, an acid reaction, and would have 
said, "Too much fat" or "Too much sugar" or "Too much 
something else," and changed the inoffensive baby's diet. As 
a matter of fact, by keeping the broader picture before us, in- 
quiring into every cause that could be concerned, we learned 
that the day preceding the disturbance there had been a change 
of nurses in the ward. This observation was repeated fre- 
quently. Almost invariably when a new nurse began her duties 

242 



PARENTERAL AND ENTERAL INFECTIONS 243 

the children temporarily became ill. Why a change of nurses 
should cause such a reaction I don't know. As I have said so 
often, "This is clinical observation." Perhaps the secret lies 
in psychic or nervous influences. At any rate, it was perfectly 
independent of food. 

2. Observations have shown that heat is important. This 
stimulated the very excellent research of McClure and Sauer at 
the Children's Memorial Hospital of Chicago.* In very inter- 
esting experiments they showed that retained heat is more im- 
portant than is the general temperature. A baby lightly clothed 
on a very hot day is less likely to become dyspeptic than is an 
overclothed baby during milder weather. 

3. Keeping the broad clinical conception of "disturbance of 
nutrition" before their eyes, Finkelstein and his assistants made 
other important observations. A new baby entered the ward; 
in a day or two every child would vomit and show watery, green, 
mucous stools. Clinical pictures varied from dyspepsia to in- 
toxication or decomposition. Had we studied the stools ex- 
clusively we would have said, "This child has received too much 
fat; or this one too much sugar"; but keeping a broader con- 
ception before us, trying to consider every factor possible, we 
learned that the secret of the matter was simply this : the food 
upon which the baby previously had been thriving could 
scarcely be the primary factor. The new baby, however, had a 
little cough or cold, a little nasopharyngitis or grip, and, if she 
were a little girl, a cystitis. During the following days every 
child in the ward started to cough and to sneeze, and, following 
this infection, reacted with diarrhea. So frequently was this 
observed that the men in that institution and in others I visited 
came to believe that these secondary diarrheas — secondary to 
little infections — were of as great or even greater importance 
than the primary food disturbances. To these infections they 
gave the name "parenteral infections," signifying thereby in- 
fections in some part of the body other than the intestinal tract. 
Gentlemen, under no circumstances forget secondary distur- 
bances due to parenteral infections. They constitute a large part 
of the diarrheal cases occurring in your children's practice. 

Are you beginning to understand how the clinical classification 
* American Journal of Diseases of Children, 1915, ix, 490. 



244 INFANT FEEDING (CHICAGO METHODS) 

of Finkelstein is helping our study? I do not for a moment 
consider it finished, but I do consider it a most valuable outline, 
by which we may direct further observations. 

Parenteral infections are so important, I want to talk about 
them for just a moment. How a cough or a cold causes diarrhea 
we do not know. Such is purely bedside observation; but 
human nature seeks explanations, and for that reason I offer the 
following. Understand, however, it is subject to great modifica- 
tion and change. 

As in the primary food disturbance the whey of cow's milk 
seems to injure the intestine and allow bacteria which are nor- 
mally present in the large intestine to flourish in the upper tract, 
so in these parenteral infections, as the stools are of the " fer- 
mentative" type, we also must have an agency stimulating bac- 
terial growth in the small intestine. How can a parenteral in- 
fection increase intestinal fermentation? Two ways become 
apparent : 

1. Finkelstein 's assistants have shown that during the prog- 
ress of these infections, the qualities of the digestive juices are 
changed. They are decreased in amount and in activity. As 
a result, two influences may be exerted: 

(a) Undigested food and sugar will proceed lower than usual 
down the intestinal tract. 

(b) The bacteria of the large intestine may come up ab- 
normally high. 

2. Products of bacterial action in the nose and throat may 
impair the function of the intestinal cells and decrease their 
ability to keep the upper intestine sterile. 

In this way, gentlemen, you see conditions in the small in- 
testine are those predisposing to disturbance of nutrition. Here, 
however, the effect produced is not by the concentrated whey of 
cow's milk, but by influences perfectly independent of food, 
namely, the products of the parenteral infection. In either 
case the presence of hungering bacteria in the small intestine 
must warn us that feeding fermentable sugar will lead to the 
production of irritating acids and resulting diarrhea. The dis- 
turbance arising from the latter, to distinguish from the primary 
disturbance induced by concentrated whey of cow's milk, we 
call a secondary disturbance of nutrition. 



PARENTERAL AND ENTERAL INFECTIONS 



245 



Just as in other conditions, this clinical picture also is in- 
fluenced greatly by the factors of age (the younger the child, 
the severer the reaction), constitution, nursing and care, heat, 
and, above all things, food. Babies fed on mixtures very high 
in carbohydrate and whey show the severest reactions. 

Diagnosis. — The diagnosis is relatively easy. 

1. History shows the child has had grip or febrile disturbance, 
followed by diarrhea. The mother calls you for the intestinal 
condition, completely ignoring the fundamental factor. Diar- 
rhea following a cold practically makes the diagnosis. 

2. Food withdrawal for twenty-four hours causes a great im- 
provement in the intestinal condition and any resulting nutri- 
tional disturbance, but does not influence the temperature. 
The following day, if the temperature is still elevated, careful 
examination of the patient shows a pneumonia or an otitis or a 
cystitis that may not have been evident upon first examination. 

Treatment. — The treatment divides itself into that of the 
primary cause and of the secondary nutritional disturbance. 

The primary injection is, of course, to be treated according 
to its nature. 

The secondary disturbance is to be guided purely and simply 
by the weight curve. If the curve rises continuously, as is the 
case in the healthy breast-fed baby, steady gain being noted 
each day in spite of abnormal intestinal movements, let that 



Davs 






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Fig. 26. 



baby alone! (Fig. 26). Don't, under any circumstances, change 
the food. See the picture! Under the influence of the parent- 



246 



INFANT FEEDING (CHICAGO METHODS) 



eral infection a little fermentation has been induced in the 
intestine, but there has been no nutritional reaction whatsoever. 
The effect is purely and simply local and intestinal, and needs no 
more food treatment than does the irritated nose in a coryza. 
The weight curve doesn't even show the reaction of a dyspepsia. 
Another type of reaction, the type which appears in the 
somewhat undernourished breast baby or in the fairly well- 
nourished bottle baby, is illustrated as follows (Fig. 27). At A 



Days 


1 






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Fig. 27. 



the child becomes infected. The accompanying fermentation is 
severe enough to produce a mild dyspepsia. The change in the 
weight curve shows that baby's nutrition is beginning to suffer. 
Shall we change the diet in this case? Let the baby alone! 
Again see the picture! The fault was not primarily with the 
food. It lay in the infection of the nose, throat, or bladder. 
A mild secondary disturbance of nutrition has arisen, but if we 
simply wait a few days, the cough and cold will disappear, and 
after the injuring factor has gone, the intestine corrects itself 
at B, the weight curve starts to ascend and diarrhea disappears. 
In these two instances treat the mother as you will, but unless he 
begins to lose weight, don't treat the baby. Let him take as much 
food as he will. He drinks less than his normal amount, and so 
spontaneously prevents the occurence of a secondary distur- 
bance. 



PARENTERAL AND ENTERAL INFECTIONS 



247 



Fundamentally different is a third type (Fig. 28), occurring in 
babies fed on one-sided carbohydrate mixtures. The baby on 
condensed milk or barley gruel, the baby with a masked type of 
decomposition, shows a sharp and severe reaction. With the 
onset of the infection diarrhea commences. The stools may not 
vary markedly from those of the other children. How misled 
we would be by focusing exclusively upon them ! But the child 
reacts with a marked disturbance, varying from a mild dyspepsia 
to the severest intoxication or decomposition. In these cases 
forget the primary factor. From his cough and cold the mother 
may think the baby is very sick, but you know that death is 



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Fig. 28. 



going to occur not from the infection, but from the severe sec- 
ondary disturbance of nutrition. First and foremost, the latter 
must receive your immediate attention, and you treat it, de- 
pending upon its nature, according to the principles laid out in 
previous lectures. 

Two symptoms arising in the course of a parenteral infection 
may need treatment: 

1. Vomiting. — If the vomiting be due to a primary food dis- 
turbance, the child recovers upon removal of the primary cause, 
namely, the food. If, however, the condition arises from a 
parenteral infection, change of food will have no effect, and 
unless we stop the vomiting we have trouble. In these cases 



248 



INFANT FEEDING (CHICAGO METHODS) 



gentle stomach washing is of value, as are also mildly anesthetic 
drugs, such as novocain, in doses of -fa grain before each meal. 
2. Anorexia. — If the loss of appetite is due to food, removal 
of the cause will cure the condition. If the cause of anorexia, 
however, is the parenteral infection, change of food will have no 
influence. In these cases physicians often make fatal errors. 
One often hears, "If the baby won't eat, we'll starve him to it." 
No graver error can be made than this. The cause of the baby's 
loss of appetite is not the food, but is the product of the paren- 
teral infection, and you may starve him and starve him, but his 
appetite will not return. What you accomplish, however, by 
introducing the factor of hunger is to throw him into the state 



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Fig. 29. 



of decomposition (Fig. 29). Many of the deaths occurring 
during mild infections are due not to this cause, but to the fac- 
tor of decomposition developing from the associated anorexia. 
Gentlemen, the baby must have food. If he takes it in no other 
way, use a stomach-tube. I don't mean, now, that you must 
get a pump and pump gallons into his stomach, but you must 
introduce small quantities, enough to keep him alive, and of 
such proportions as to avoid the dangers of a secondary dyspep- 
sia or intoxication. 

The factors of heat, of food, of parenteral infection, and of 
care usually are all concerned in these dyspepsias and intoxica- 



PARENTERAL AND ENTERAL INFECTIONS 249 

tions. In recognition Finkelstein suggests classifying them 
etiologically as follows: 

I. Purely alimentary or food type. 
II. Mixed type (in which all influences are concerned). 



INFECTIOUS DIARRHEAS 

Gentlemen, we have now finished the "Disturbances of Nu- 
trition." I want to take you far away for a moment to view an 
entirely different group of diseases. While the success of high 
protein, low whey, non-fermentable carbohydrate was attested 
by the consensus of opinion of the whole world; while in the 
Finkelstein clinic a great international assemblage of men had 
collected, — men from America, England, Austria, Russia, Japan, 
Bulgaria, Rumania, Switzerland, Portugal, and other coun- 
tries, — all testifying to the great influence of these teachings, a 
communication came from A. I. Kendall, of the Boston Floating 
Hospital, saying that the treatment of severe diarrhea was low 
protein and high carbohydrate. Could anything be more tan- 
talizing, more aggravating? Just at the moment when we 
thought the problem of diarrhea in children forever solved, 
when we thought the infallible remedy for all diarrhea was high 
protein, low whey, non-fermentable carbohydrate, we must 
read that the proper treatment is low protein, high carbohy- 
drate, and carbohydrate in a fermentable form, such as lactose. 
The first inclination was to do as always, when some one dis- 
agrees with us — to question the writer's sanity. Careful study 
of the publication, however, showed that Kendall was speaking 
of a group of diseases entirely different from those we were 
studying. His work had to do with the true infectious diar- 
rheas — those due to specific microorganisms; the type of case 
we did not see. The communication was so interesting that I 
resolved, upon my return to this country, to try to meet Ken- 
dall. To my great pleasure I learned that he had been called to 
take charge of the Department of Bacteriology at Northwestern 
University Medical School, the institution with which I was to 
be connected. He, with the true interest of the bacteriologist, 
was concerned mainly with the deadly infectious diarrheas: I 
chiefly with the question of nutrition. To settle the point as 



250 INFANT FEEDING (CHICAGO METHODS) 

regards the nature of material in Chicago, we made a study 
during the summer of 1914. 

Dr. Alexander Day, one of Kendall's associates on the Boston 
Floating Hospital, examined bacteriologically all cases of severe 
diarrhea in our wards. He cultured carefully all the stools, 
while I studied the cases from the standpoint of " nutritional 
disturbance," looking at them clinically and noting their weight 
and food reactions. Our results showed that, during this sum- 
mer, in our wards in Chicago, one or two cases of diarrhea showed 
the gas bacillus in the stools; two cases showed reactions to food 
typical of the primary food disturbances, and the remainder 
were those associated with coughs and colds — the so-called 
parenteral infections. During a study made the following year 
we found two cases of severe dysentery sent to the hospital 
from out of town — cases entirely different in nature from our 
own, and showing symptoms identical in every respect to the 
dysentery infection which Kendall had noted in Boston. In the 
stools Dr. Day discovered the true organisms of dysentery. 

Why is it that in Boston infectious diarrheas and in Chicago 
nutritional disturbances prevail? The failure to discover in- 
fectious diarrheas in Chicago could not have been due to technic, 
as the investigations were conducted by the same men. We 
must regard these results as conclusive. Day and I offered the 
explanation that, in the sense of Brennemann, the difference may 
be due to the fact that in the East raw milk had been used, and 
in Chicago, boiled milk. Isn't it reasonable to assume that in 
the East, with raw milk, infectious diarrheas prevail; in the 
middle West, where these organisms have been removed by 
boiling, nutritional disturbances only are seen? 

Gentlemen, in this part of the country probably many of your 
patients use raw milk. When you are called to see a baby with 
diarrhea, you are at once confronted with the problem, "Is 
this an infectious diarrhea or is it one of the nutritional type?" 
To distinguish between these is of fundamental importance. 
We have several means. 

History. — The acute infectious diarrhea starts suddenly in a 
previously well baby and prostrates him at once. The nutri- 
tional disturbance comes more gradually. In the latter we 
get a history of improper feeding, of previous nutritional dis- 



PARENTERAL AND ENTERAL INFECTIONS 251 

turbance, of parenteral infection. It is more gradually pro- 
gressive. 

Stools. — These are of considerable aid in our diagnosis. In 
the infectious diarrhea, particularly dysentery, they are very fre- 
quent, small, and chiefly blood-stained mucus. They contain 
barely any solid material, and the microscope reveals pus. 
They may be identical to the evacuations in intussusception. 
The reaction in dysentery is alkaline. In nutritional distur- 
bance the stools are green, usually acid, and watery. They con- 
tain increased solid material and some mucus; rarely blood or 
pus unless the case has long been neglected. 

The reaction to food is of value. If, after twenty-four hours 
of tea, the temperature continues high, the weight curve sinks, 
the diarrhea continues, with small, bloody, mucous stools, then 
some factor other than food must be at hand. If careful physical 
examination rules out parenteral infection, such as pneumonia 
or sepsis, the diagnosis, by exclusion, will be enteral infec- 
tion. 

Treatment. — Gentlemen, what I have to tell you about the 
treatment of true infectious diarrheas will be disappointing. 
AH that I can do is to expose our ignorance. The treatment de- 
pends just as absolutely upon definite bacteriologic diagnosis as 
that of diphtheria depends upon throat culture. How to treat 
cases of infectious diarrhea in this part of the country I do not 
know, for I have absolutely no idea what types of infection you 
meet. If it is a gas bacillus, one food must be given; if it is a 
dysentery bacillus, radically the opposite treatment must be 
instituted. Bacteriologic methods of diagnosis are difficult — a 
trained bacteriologist is necessary. An agglutination reaction 
in dysentery, such as the Widal in typhoid, can be of service. 
All that I can do, gentlemen, is to urge you, in connection with 
your medical society, to cooperate with the State Board of 
Health or with the State University in attempting to discover 
what types of infection exist here. 

I won't bother you with the technic for isolating the dysen- 
tery organisms. The gas bacillus, however, can be detected 
relatively simply: 

To get a sterile specimen of the baby's stool, round the ends 
of a piece of sterile glass tubing about the thickness of a lead- 



252 INFANT FEEDING (CHICAGO METHODS) 

pencil, and insert it into the rectum as you would a thermometer. 
Usually a little fecal material enters. If the rectum is empty, 
repeat in an hour. Then inoculate a small quantity of the stool } 
about the size of a pea, into a test-tube of milk. This is heated 
to 180° F. for half an hour. All bacteria are killed except the 
spores, which resist heat, and, when the milk is incubated at 
body temperature, grow rapidly. If they be those of the gas 
bacillus, they split sugar into acetic and butyric acids, and char- 
acteristically give the odor of rancid butter. Secondly, the 
acid causes the casein to coagulate. This precipitates in large 
curds, but, due to the growth of the gas bacillus, has the appear- 
ance of being completely "shot to pieces." Lastly, the micro- 
scope shows the large Gram-positive bacillus. 

The treatment for gas bacillus infection, according to Kendall, 
is based upon the observations that the organism grows well in 
sugar and does not grow well on high protein or lactic acid. In 
such an infection, therefore, the treatment is buttermilk. Al- 
bumin milk, due to its high protein, low carbohydrate, and lactic 
acid, would also be ideal. Kendall made the interesting sug- 
gestion that perhaps some of the cases that Finkelstein treated 
so successfully with albumin milk were really those of gas bacil- 
lus infection. This is a very interesting suggestion, but I don't 
believe will prove true as a general rule. 

The treatment of true infectious dysentery is based upon 
entirely different principles. Here great ragged ulcers line the 
intestine. In these the dysentery organisms live and produce 
toxins, just as do diphtheria bacilli, from their location in the 
throat. Death occurs in dysentery largely from toxemia. You 
see then, gentlemen, how hopeless is drug therapy. We may 
give calomel. We may give medication to flush out the intes- 
tine. With small quantities we may do no harm. To me, 
however, giving cathartics in such cases suggests reaching in 
with a forceps and tearing out the membrane of diphtheria. 
What folly ! If our sole therapy in diphtheria is physical injury, 
we kill the baby. Our treatment lies in antitoxin; and so it is 
with dysentery. Our ultimate success must lie in the adminis- 
tration of antitoxin if we can give it in time. 

In speaking of calomel, gentlemen, I understand that it is 
used considerably down here and that you place great faith in it. 



PARENTERAL AND ENTERAL INFECTIONS 253 

It may be very efficient. I do not know, because I do not know 
the existing types of infection. May be you have organisms to 
which calomel is deadly. That remains to be seen. After all, 
the wisest is to establish means for obtaining definite diagnosis. 

The general treatment of dysentery must be that of all in- 
fectious disease. Keep up the fluids, provide proper nursing 
and care, stimulate if necessary. Opium is of great value. In 
nutritional diarrheas opium, by disguising the symptoms, might 
lull us into an insecure, dangerous self-satisfaction. In dysen- 
tery, however, where the bacillus and not the food is the cause, 
we disguise no symptoms with opium, but quiet our little pa- 
tient and relieve the pain and tenesmus. Give as much as you 
can with safety. As regards medication, quinin tannate, in 
doses of 3 to 5 grains three times a day, is highly recommended; 
but, as I have said so frequently, do not put too much confidence 
in drugs. 

The dietetic treatment is radically different from that of 
nutritional disturbance and from gas-bacillus infection. Theo- 
bald Smith, the great American bacteriologist, years ago ob- 
served that if the diphtheria bacillus be grown on carbohydrate 
it will not produce toxin, but if grown on protein, it produces 
the typical toxin of diphtheria. Kendall, working from this 
viewpoint, experimented with dysentery and found that if it 
be grown on carbohydrate, no poison is produced, while if 
grown on protein, the deadly dysentery toxin results. This 
explains, then, why in dysentery he advocated high carbohy- 
drate feeding. He wished to get carbohydrate to the organisms 
growing in the intestine, thus preventing the formation of toxin. 
Two forms of dietetic treatment may be employed : 

1. Breast Milk. — Breast milk with low protein and high car- 
oohydrate is a food ideal for Kendall's requirements, and at the 
same time does not endanger the child from a nutritional stand- 
point. 

2. The Frank Treatment. — This is the most successful of 
artificial feedings. • I give it as recommended: 

(a) Tea for twenty-four hours, except in cases of decomposi- 
tion. 

(b) On the second day start with five feedings, each of which 
is composed of two ounces of whey and two ounces of gruel. 



254 INFANT FEEDING (CHICAGO METHODS) 

(c) Gradually increase by the fourth or fifth day to five feed- 
ings of 2j/2 ounces each. 

(d) On the fifth to the eighth day, in teaspoonful doses, slowly 
replace the whey by milk. See the importance of diagnosis! 
We have ordered a mixture of sugar, salts, and barely any pro- 
tein for five days. This would have been the worst possible in 
nutritional disturbance or gas-bacillus infection. 

(e) On the twelfth to fourteenth day, perfectly independent 
of the stools, the patient must be getting 13 to 14 ounces of gruel, 
13 to 14 ounces of milk, and 6 to 7 ounces of broth. He also may 
receive a little cereal, as rice, farina, Cream of Wheat, etc., and, 
if over one year of age, a little meat. 

This is the most successful up-to-date treatment for infection 
with true dysentery. How complicated, how long, often how 
unavailing! Why not with one stroke save your patients and 
yourselves all this wearisome treatment and danger, practise a 
little prophylaxis, and boil the milk? 

We have now finished the subject of nutritional diseases. 
We have given you some of the viewpoints developed in the 
great European clinics and adopted in the middle West. You 
may have wondered at the hours given to nutritional conditions, 
and have been disappointed in the few words given to infection. 
Time prevents a thorough consideration of everything. I laid 
most emphasis upon the former, with the idea of preparing you 
for the future. I believe that if you boil your milk, disturbance 
of nutrition will be the type preeminent, the picture which will 
become more and more apparent in your practice. 

I have spoken chiefly of our ideas in Chicago. Other view- 
points you may obtain from the many excellent American text- 
books on the subject. We prefer the clinical classification be- 
cause we believe the broad conceptions in it will aid us in further 
study. We like the term " disturbance of nutrition," rather 
than that of gastro-intestinal disease, because we believe this 
conception prevents our focusing too closely upon the stool. 
Even though the primary causative factor lay in the intestinal 
canal, we believe the baby's general condition far more im- 
portant than his gastro-intestinal tract. Our whole plan of 
feeding and therapy depends not upon the stool, but upon the 
weight curoe. We believe the latter, if controlled by conscientious 



PARENTERAL AND ENTERAL INFECTIONS 255 

history and physical examination, gives the best index of the 
baby's general condition, of the combined influences exerted by 
"food," by "intestine," and by "demands of the body" 

Just one word more. A recent communication of 1916 from 
Dr. Louis W. Hill, of Boston, who is conducting so successfully 
the sections in the East, divides diarrheas into three groups, 
namely : 

1. The infectious type. 

2. The nervous type. 

3. The fermentative type. 

Regarding the latter, he goes into some length, showing the 
antagonistic effects of protein and carbohydrate, laying emphasis 
upon carbohydrate fermentation in the production of the irri- 
tating lower fatty acids, and recognizing carbohydrate as a 
primary factor even in some cases where much fat is excreted. 

There must then be very little difference between the opinions 
of the East and middle West. Why have we disputed? Powers 
of observation do not depend upon geographical location. 
There must be some deeper factor, some truer explanation. 
One thought constantly repeats itself in my mind : Cannot the 
whole difference be explained upon the basis of boiled milk? 
Isn't it possible that conditions in the East are undergoing evo- 
lution; that during the period of raw milk, pictures of the spec- 
tacular, deadly infectious diarrheas exclusively prevailed? But 
now, as I understand it, boiled milk is coming into its own. 
Isn't it possible that for the first time, the gradual waning of 
infectious diarrhea reveals the rise of disturbances of nutrition? 
We eagerly shall await new developments. 



LECTURE VIE 
ARTIFICIAL FEEDING OF THE NORMAL INFANT 

Gentlemen, artificial feeding in the middle West has developed 
from the studies we have described. We never start with a 
preconceived idea as regards a definite and exact formula, but 
by knowledge of the various disturbances arising from improper 
combinations we select mixtures to avoid them. The funda- 
mental requisite in infant feeding is a little good common sense. 

Before going into detail, it might be well to rid ourselves of a 
few conceits. A young animal, even if starved, nevertheless 
continues to grow. He will not gain in weight, but he will in 
size. So it is with the baby. Don't for a moment think that 
you are responsible for the baby's growing. You simply offer 
him bricks and mortar for his tissues, but you certainly are not 
responsible entirely for his growth. Don't take yourselves too 
seriously. You are an outside factor, an external influence — 
important, it is true, but by no means the sole cause of baby's 
thriving. 

Remember that the mother does not feed the baby at the 
breast. The baby feeds himself. The mother does not start 
with the preconceived idea of how much, of how many ounces, 
she is going to give the baby. She simply puts him to the breast, 
he takes what he wants, and when satisfied, stops. 

Gentlemen, get the idea out of your head that you are going 
to feed the baby. Leave a litttle of the responsibility to him! 

Remember, by all means, that the baby is human. Think of 
yourselves, for instance; your appetite varies depending upon 
the weather, upon your mood, upon the nature of the food. 
On a hot day you eat less ; on a cold day, more. Amounts vary 
daily. Some of you are vegetarians; some of you meat eaters; 
some of you not particular. So it is with the baby. Remember 
that he is human, that his appetite will vary, that no two babies 

256 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 257 

are alike; meet him half-way, and rather than expect all con- 
cessions from him, make a reasonable attempt to adjust your 
mixtures to his demands. 

Remember that when we eat our fundamental worry is "will 
this food agree with us?" If we take our meal without digestive 
trouble; if we get the food past the intestinal tract into the 
body, our troubles largely are over. The body uses what it 
needs and throws out the excess. Why should the baby be 
different? Any food which easily and harmlessly passes the 
intestinal tract into the body, and at the same time contains 
enough bricks and stones and mortar for the body tissues, will 
provide for the baby's growth. He retains what he needs and 
casts out any excess, whether it be breast milk or cow's milk. 

Thus, you see, many systems of feeding may be successful. 
There is no one system which is exclusively right — many meth- 
ods are right. Our main concern is simplicity. We must ans- 
wer the body requirements and employ the intestine simply as 
an agent for introducing food-stuffs. 

How often shall we offer food? Opinion varies from two to 
four hours. Czerny advises adhering rigidly to the four-hour 
schedule—five feedings in twenty-four hours: at 6, 10, 2, 6, and 
10 o'clock, and from 10 at night to 6 in the morning the baby to 
receive nothing. He insists upon this schedule for all babies, 
and undoubtedly this method is attended with much success. 
The claims in favor of it are: first, it is scientific (based upon 
physiological reasoning), and second, it is a great help and con- 
venience to the mother. From my own experience, I find many 
children do well on four-hour nursings, but it seems to me also 
that many of those under two to three months do not seem 
satisfied when made to wait so long and do better on a three- 
hour schedule. And so, as a matter of routine, I order for all 
children under two to three months seven feedings — at 6, 9, 12, 
3, 6, and 9 o'clock and once during the night. Undoubtedly, 
however, many of these would do just as well on the Czerny 
s} r stem, and when they do, it is a great convenience to the 
mother. 

Recently the very interesting experimental work of Professor 
A. J. Carlson, of the University of Chicago, — who has done so 
much to clear up the physiology of hunger, — goes to show that 
17 



258 INFANT FEEDING (CHICAGO METHODS) 

perhaps, after all, the three-hour system is based upon more 
scientific principles than the four-hour one. 

The number of feedings varies somewhat with locality. I 
believe in the East they feed more frequently than we do. A 
simple experiment which we made in the Finkelstein Clinic 
might explain these differences. Babies in some wards we fed 
according to the percentage method; babies in others we fed 
according to the methods I am about to teach you. All were 
given five feedings in twenty-four hours. The percentage 
babies vomited more than did the others. As the percentage 
method frequently requires more fat than does ours, we rea- 
soned that this vomiting might possibly be due to the fat, i. e., 
to the irritating lower fatty acids contained in cow's milk fat. 
Empirically we controlled this vomiting by feeding smaller 
quantities more frequently; so in a short time all the percentage 
babies received several more feedings a day than did the others, 
and all thrived beautifully. This may help explain the differ- 
ence in the various feeding schedules. 

• What shall we offer? Almost any system of feeding has its 
ardent advocates. The possibilities of the normal child's in- 
testinal tract are immense. The normal baby thrives upon a 
great number of mixtures. Therefore it's easy to understand 
how many different systems have arisen, each with its enthusias- 
tic adherents. The French, for instance, have at times recom- 
mended full boiled milk. Many children do well on this; some 
don't. Biedert, one of the older German pediatricians (he it 
was who first described casein curds in the baby's stool), recom- 
mended the dilution of whole milk to lower the protein. To 
make up for the loss in strength he added cream and sugar. 
The resulting combination resembled somewhat a percentage 
mixture. Some children thrived beautifully; some did not. 

Heubner brought calories to our notice. He first advocated 
feeding 45 calories per pound body weight for children under 
six months. This system is not ideal, as you readily see. A 
child's bottle may contain the proper number of calories, but 
they may be only in fat or in sugar, and will not satisfy the de- 
mands of his body tissues. Again, newer studies show that 
mysterious invisible substances, called vitamins, play important 
roles in growth. The excellent work of the men at the Uni- 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 259 

versity of Wisconsin already has subdivided this new group into 
fat-soluble substances found in butter, and water-soluble sub- 
stances found in wheat embryo, both of which are absolutely 
essential to an animal's growth. These, of course, cannot be 
measured by caloric value. We of the Middle West do not 
follow rigidly, but we value the caloric system chiefly as a check 
upon us, and when a baby is not gaining, we occasionally run 
over the formula and estimate approximately how many calories 
it represents. But let me emphasize that we do not advocate 
this as a method of feeding. It is simply a check upon the fuel 
value of food that we are offering. 

An ingenious advance was the percentage system, used by 
our friends in the Elast. It was first devised for the purpose of 
making the relations of protein, fat, and carbohydrate in cow's 
milk similar to those in breast milk, but, as I understand it, 
now is offered simply "as a method of calculation and a means 
of attaining relative accuracy in the preparation of infant's 
foods." For such a purpose we welcome it heartily. We of 
the Middle West do not use it, not because we object to accur- 
acy, but because we find the percentage formulae somewhat 
cumbersome and because we accomplish excellent results with 
methods which to us seem simpler. 

Ludwig F. Meyer once said to me: "What an ideal combina- 
tion would result if one would take your percentage method of 
feeding, striving as it does for accuracy, and adapt it to the 
principles we are attempting to develop!" Gentlemen, I think 
tliis would be a step in the right direction. In this entire course 
I have attempted to teach you not rules, but principles. You 
know that in infants fed with boiled milk we consider most dis- 
turbances due to fermentation of carbohydrate, induced either 
primarily by improper relation to the whey, or to the fat and 
whey; or secondarily to one of many parenteral factors. In all 
cases, however, we pay far more attention to the baby as a whole 
than to his intestinal tract. Gentlemen, don't forget these 
principles. With them you may face any nutritional distur- 
bance with equanimity. Make up your mixtures as you will. 
By all means strive for accuracy. If you find the percentage 
method of calculation of value as a check, use it. From our 
system of feeding, however, has developed, I believe, the simplest 



260 INFANT FEEDING (CHICAGO METHODS) 

technic for answering the above requirements. But any simpler 
method of calculation which will enable us, while still being 
true to our principles, to make up mixtures with even greater 
accuracy, we shall always be glad to adopt. 



METHODS OF THE MEDDLE WEST 

Our system is prophylactic from the start. We have learned 
that the fault does not lie exclusively with one element of the 
milk: that it depends upon improper relations of the different 
elements. Thus, if we give much sugar in concentrated whey, 
diarrhea results; if we give the same sugar in highly diluted 
whey, the chances of disturbance are decreased. If we give fat 
in combination with high carbohydrate in a medium of cow's 
milk, we frequently have trouble. The fat may be involved 
either primarily or secondarily. If, however, we give this very 
same fat in combination with albumin milk, viz., with high pro- 
tein, low whey, and non-fermentable carbohydrate, the fat 
becomes harmless. Fat in an acid intestine enhances diarrhea; 
in an alkaline intestine, enhances constipation. Again, we may 
offer rather concentrated whey, even as full milk, which the 
French have done, and experience no difficulty whatsoever until 
carbohydrate is added. In our feeding we attempt to dilute all 
elements of the milk and to make our additions with only one. 
In the baby's intestine high fat and high sugar in cow's milk are 
not agreeable companions. Prophylaxis is our motto, and we 
proceed as follows : 

1. To protect our baby from dysentery and other virulent 
infections, and to prevent the formation of tough casein curds, we 
boil the milk. 

2. To prevent the accusation that we are predisposing to 
scurvy we add, at the end of the first month, orange-juice in 
doses of a teaspoonful each day. Dr. Alfred Hess, of New 
York, has shown this to be extremely important. 

3. To prevent the danger of overfeeding, we are careful as to 
the total quantity of food. How much do we offer? Naturally, 
the amount in each bottle must depend upon the fuel value of 
the food and the number of feedings: the more frequent the 
feedings, the less the individual quantity. But don't try to 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 261 

follow any hard and fast outline. Remember, we are treating 
babies, not manufacturing rules. In a general way the first 
time we see a child we guide ourselves as follows : 

(a) By the end of the second week an infant will drink in 
twenty-four hours a total of roughly 15 ounces, increasing to 
20 ounces by the end of the first month. 

(6) During the second month he increases this total to 25 
ounces. 

(c) During the third month he drinks a quart 

This is no rigid routine. Some babies take more; some less. 
Try the baby on this amount and see how he reacts. The first 
formula is really a feeding experiment. 

4. To protect the child from nutritional disturbances arising 
from improper relations of the various ingredients, we bear the 
following picture in mind. I do not believe you will find it 
formulated just as I give it, but in a way it represents our point 
of view (Fig. 30). 



Well Baby 
Disturbed Balance*^ i =^Dyspepflia 

Docon^position N^ Intoxication 

Fig. 30. 

This illustration shows the well baby included in the group 
of sick babies, and suggests that this very same well baby can be 
made to assume any one of four clinical types. The factors 
concerned in these changes are the improper usage of carbohy- 
drate and whey and the improper understanding of the role of 
fat as a secondary factor. The conditions on the right develop 
from too high carbohydrate in concentrated whey; the condi- 
tions on the left arise, as Czerny would have said, from too much 
fat; as Finkelstein would say, from too little sugar. Of course, 
constitution, infection, etc., are important accessory agents. 

What is the purpose of this scheme? It suggests that our 
attitude must be identical to that, for example, in typhoid fever. 
In typhoid we don't treat the disease : we simply try to guide our 
patient through the difficulties that lie in his path; and so it is 
with infant feeding. We don't feed the baby : we simply guide 



262 INFANT FEEDING (CHICAGO METHODS) 

him. In ordinarily diluted milk we try to avoid the dangers of 
excessive carbohydrate, on the one hand, and of insufficient car- 
bohydrate, on the other. 

5. The next step in our scheme of prophylaxis requires a care- 
ful history and physical examination of the patient. If he be a 
weak child; if he have dyspepsia; if he have a parenteral infec- 
tion; if he be suffering from poor care, we must be careful as to 
ordering a high percent of carbohydrate — never over 3 percent to 
begin with. If the examination suggest a condition of disturbed 
balance, or if the child be recovering from an infection, he needs 
increased carbohydrate or at any rate increased energy. Our prob- 
lem in the latter case is to offer the increased carbohydrate to 
the body in such a way as not to endanger the intestine. 

How shall we make mixtures to avoid intestinal complication? 
Gentlemen, this sounds complicated, but it is extremely simple. 
There is nothing to it. You may banish from your minds any 
worries regarding the difficulties of infant feeding. It's the 
simplest branch of pediatrics! Simplicity is our motto, and, 
indeed, so simple is our method that any novice can use it suc- 
cessfully. To illustrate: In our stomachs a great quantity of 
hydrochloric acid is secreted daily, but this acid is very dilute. 
The same total quantity in concentrated form would be deadly. 
So it is with milk. Train yourselves to think in terms of con- 
centrations — the more dilute the mixture, the less injurious to 
the intestinal tract and to the body tissues after its absorption. 

1. For the first four weeks we use one part milk and two parts 
water — one-third milk. 

2. During the second month we use equal parts of milk and 
water — one-half milk. 

3. From the beginning or middle of the third month we use 
two parts milk and one part water — two-thirds milk. 

In these mixtures, as the strength of the milk is weakened, 
we must offer additional food, and preferably one element rather 
than two. This is done best by adding carbohydrate in non- 
fermentable form, such as dextri-maltose, etc. We use ap- 
proximately 3 percent the first time we see the child, and, de- 
pending upon the reaction, increase gradually to 5. 

To illustrate : Suppose we saw for the first time a normal baby 
of one month. We would say: This child shall receive a con- 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 263 

centration of one-half milk. He drinks roughly 20 ounces a day, 
so we'll order — 

Milk 10 ounces 

Water 10 " 

Add 3 percent of dextri-maltose or, roughly, five teaspoons. 
Boil for one minute, and divide into seven bottles of about 
2^ ounces each. 

If the child were three and one-half months old, we'd say: 
He can tolerate a concentration of two-thirds milk and drinks 
a quart a day, so we'll order — 

Milk 20 ounces 

Water 11 " 

Add 3 percent of dextri-maltose, or about eight teaspoons. 
Boil and divide into five bottles of six ounces each. 

Don't take these mixtures as final; simply make up one on 
such principles and then adapt it to the baby. Some of our 
Chicago pediatricians make practical application of these prin- 
ciples in a slightly different way. During the first few months 
they order slightly greater concentrations of milk than the above 
and avoid disturbance from the concentrated whey by keeping 
the carbohydrate low, i. e. , 1 to 2 percent. The writer prefers the 
more dilute mixtures with higher carbohydrate, however, for 
two reasons: 

(a) Constipation of an obstinate nature is less likely to 
result with the higher carbohydrate diet. The concentrated 
mixtures with low sugar lead to putrefactive processes in the 
intestines, and, although the babies thrive perfectly, probably 
using the protein for energy, the mothers are never satisfied. 

(b) On the more concentrated mixtures with lower carbo- 
hydrate children often drink greater total quantities than 
those on the less concentrated, higher carbohydrate diets. 
While in private practice and infant welfare work, where 
children receive individual attention, they thrive perfectly, 
in hospital wards these larger quantities frequently induce 
vomiting. 

During these first months, what shall be our guide? How 
shall we know that the baby is doing well? Gentlemen, under 
all circumstances let the weight curve, controlled by history and 



264 INFANT FEEDING (CHICAGO METHODS) 

physical examination, be your index. If the baby is gaining an 
average of five to seven ounces per week, and at the same time 
seems clinically well, let him alone. No matter though his stools 
be a little dyspeptic ; no matter if he have a slight colic or slight 
diarrhea: if he is gaining in weight, let him alone. Your main 
difficulty will be in treating the mother, particularly the mother 
of the first baby. She sits at the bedside ; in one hand she clasps 
" Mother So and So's Guide to Infant Feeding," " based upon 
forty years' experience." She searches each stool, seizes with 
enthusiasm upon any slight abnormality, as a tiny curd of fat 
or a little mucus, and tells you, with gloomy joy, that the food 
is not agreeing with her baby. Under these circumstances treat 
her as you will. Tell her that the condition is normal; that 
Mother So and So's book is old-fashioned. Do anything you 
wish: but let the baby alone. 

In a few conditions gain of weight may be deceptive. High 
sugar mixtures, as condensed milk, and particularly mixtures 
rich in both sugar and salt, may cause water-logging of the body 
and not an increase in true tissue substance. Salt in itself may 
do this in certain types of nephritis. In fever there is often 
acute retention of water, with a corresponding gain in weight, 
and again we know that a child may be gaining nicely and at 
the same time develop rickets. But history and physical exami- 
nation easily will preclude such errors, and knowing the dangers 
in advance, you will avoid them. 

During the first months you must see the baby or hear from 
the mother every few weeks, and you will be called to meet 
several indications. 

(a) The child may vomit. This we will discuss under Breast 
Feeding. But remember not to get excited. If the baby is 
gaining, tell the mother the vomiting is of no significance, is 
normal, and make no change unless vomiting is very severe, 
when you might reduce the day's total feeding by a few ounces. 
If the baby is not gaining, it might be better to make no change 
in the day's total, and give a greater number of feedings, thus 
decreasing the amount in each bottle. 

(6) The child may not gain, and the weight curve become 
straight or begin to drop. The stools are not more than two or 
three per day. Under these conditions take the mother into 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 265 

your confidence — many mothers really have more intelligence 
than we imagine; ask if the baby seems hungry; does he cry 
directly after finishing his bottle, put his fingers into his mouth 
between feedings, fret before the next bottle, seize it with avidity 
and drain it rapidly? If so, increase the total quantity of food 
by a few ounces, making no change in the proportions. How- 
ever, if he seems satisfied with the quantity, one could increase 
the milk exclusively an ounce or two, or the carbohydrate ex- 
clusively by 1 to 2 percent, but not both together. 

(c) If he is not gaining, does not seem extremely hungry, and 
is suffering from constipation, then it is perfectly safe to in- 
crease the proportion of carbohydrate in the diet to 4 or 5 per- 
cent. In this increase we have a true means of winning mother's 
affection. If our increase is in non-fermentable carbohydrate, 
gain in weight may result, but the constipation will persist. 
If we increase with fermentable carbohydrate, such as milk- 
sugar, or, more simply, cane-sugar, not only will gain in weight 
result, but the resulting fermentation corrects constipation. 
So, by striking the proper balance between dextrin-maltose, on 
the one hand, and fermentable carbohydrate, on the other, we 
have a means of regulating absolutely the condition of the intes- 
tine and of bringing joy to the anxious mother's heart. 

(d) If the weight curve straightens out, but at the same time 
the stools are four to five daily and fermentative, we are con- 
fronted with the one problem that may arise in this system of 
feeding. Dyspeptic stools may be a symptom of underfeeding 
or beginning dyspepsia. History and physical examination aid 
us greatly. If the child shows definite symptoms of hunger; 
if questioning shows the mother has not of her own accord made 
changes in the mixture, and if examination shows that the child 
looks well, then it is safe cautiously to increase slightly the 
amount of food, noting the reaction. Here one never would 
increase the proportion of carbohydrate, but simply the total 
quantity, not changing the relations of the different elements. 
If, on the other hand, the child shows a tendency to avoid food, 
— these little children often are so much wiser than we, — if 
examination shows him not looking well, slightly feverish, rings 
under his eyes, and, above all things, that mysterious change 
in the skin (the rosy pink becoming an ashen gray), we know we 



266 



INFANT FEEDING (CHICAGO METHODS) 



are dealing with a case of beginning dyspepsia. Now, an in- 
crease of food will make the disturbance worse. Give the baby 
only the quantity he wishes and await results. 



Dave 


3 




, 


> 


• 51 


, 


* 


i 




li 


>i 


t 




4 02 


































2 03 

8 lb 


































































































« 


/' 































Fig. 31. 



(e) If, in connection with the fermentative stool and the 
child's change of appearance, the weight curve definitely starts 
to drop, then we are dealing with dyspepsia, beginning intoxica- 
tion, or decomposition, and treatment must be instituted ac- 
cordingly (Fig. 31). 

(/) If the baby isn't gaining, we rarely increase the day's total 
much over a quart. Many men give 40 ounces or more. The 
reason I do not is that on the breast the baby doesn't get much 
over a quart. A larger quantity throws an excess of water into 
the system, and why burden the baby's metabolism with taking 
care of this excess of fluid? We know that from birth on the 
body becomes relatively poorer and poorer in water. If at the 
fifth month the baby ceases to gain, offer more food in the form 
of cereal and a slowly increasing mixed diet. My own impres- 
sion is that when once on a mixed diet, children are more im- 
mune to infections and to nutritional disturbances than those 
on large quantities of fluid. 

In all cases, by watching our weight curve and by studying 
our little patient carefully, we can check most disturbances be- 
fore they develop, and the severe conditions will be few indeed. 

What is the advantage of our method over the others? Per- 
haps its extreme simplicity. Any method used by one trained 
in its application will be successful. Our method, however, we 
believe easiest for the untrained man — the man who has not 
had time to work up his own technic. 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 267 

As an example of this let me quote my experiences in the 
Chicago Infant Welfare Society. This organization was founded 
by private subscription some six or seven years ago. Its object 
was not charity, but education. The idea was to reduce infant 
mortality, not by medical treatment, but by prophylaxis; not 
by curing the sick baby, but by keeping the well baby well. 
With this end in view one station was organized in our poorer 
districts. A physician attended twice a week. A salaried 
nurse was in charge. Mothers were urged to bring their well 
babies for advice as to feeding, and during the intervals between 
conferences the nurse went into the home and gave simple in- 
struction as to the technic of making the mixtures. No medi- 
cine was given ; no milk supplied. The mothers could buy their 
milk where and from whom they chose. At the station they 
got nothing but advise. 

Gentlemen, the success of this new experiment was astound- 
ing. The swarms of mothers nocking to the first station, the 
immediate lowering of infant mortality, were all the evidence 
necessary to show the success of this new departure. Under the 
able leadership of Dr. H. F. Helmholz and Dr. Walter Hoffmann, 
the organization has grown in the last few years from the origi- 
nal one station to 21. The numbers of infants seen in an after- 
noon average about 30, but often reach 50. Wherever a station 
is opened, in that district infant mortality drops. This exper- 
ience was in a way very humiliating to me. I served the Society 
for several years as assistant medical director. During that 
time I had ten or eleven stations under my charge and visited 
them each once a month. I saw many men for the first time 
come to take charge; saw these men instructed in the above 
simple methods of feeding, and saw these men in a very few 
weeks' time obtain just as successful results as I did with a much 
wider experience. They had never read Finkelstein or Czerny 
or Heubner; but the results accomplished were all that were 
necessary. Nothing speaks more for the simplicity of our feed- 
ing than the success of the Infant Welfare Society. True distur- 
bances of nutrition rarely arise. The children become simply 
" feeders." 

In this work, gentlemen, one fact has impressed me most 
strongly. That is the fundamental, the previously unrecog- 



268 INFANT FEEDING (CHICAGO METHODS) 

nized, but indispensable, services of our nurses. We, in the 
stations or in the dispensaries, see the baby for a moment and 
write out a formula for the milk mixture; the nurse, however, 
goes into the home and meets the true condition. She sees all 
the great influences which are at work, — the accessory aiding 
influences, — the influences which constantly are undermining 
the baby's constitution and upsetting our plans. She instructs 
the mother as to proper clothing; she teaches that on a warm 
summer's day it is unwise to wrap the baby up in thick layers, 
surround him with a pillow, or place him near the kitchen stove. 
She informs the mother about the dangers of flies, and attempts 
in a simple way to protect the child from these pests. She shows 
how to bathe the baby. She dwells upon the importance of 
regularity of feeding; she demonstrates the proper care of the 
bottle and the cleansing of the rubber nipple ; she shows how to 
keep the milk cool if no ice-box is available, by placing the bottle 
in a tub of cool water; in short, she fulfils the indications which 
Schlossman so pointedly expressed when he said, " A good nurse 
can always overcome the mistakes of any poor physician." 

Gentlemen, those of you who are interested in infant feeding, 
those who wish wider experience in dealing with nurslings, those 
who wish to do inestimable good in the poorer districts, should 
attempt to establish an Infant Welfare Society; and, in your 
own practice, profit by the lessons that we have learned. Where 
these splendid nurses are not available, be yourselves a little 
more the nurse, a little less the physician. Explain clearly to 
the mother that she is not doing her duty simply by mixing the 
milk in the proportions you have suggested, but that she must 
fulfil all the other requirements which are so essential to the 
baby's general health, and without which any system of feeding 
will fail. If you will only lay sufficient emphasis upon the 
nursing care of your infants, the feeding will almost take care 
of itself. 

Have we spoken the last word? Is our method going to last? 
I do not think so. New advances constantly will be made — 
ones we shall adopt, no matter what their source. I believe 
that we have mastered the art of guiding food past the intestinal 
tract into the body, but rather than rest upon our laurels we 
must arise to attack newer and more intricate problems — ones 



ARTIFICIAL FEEDING OF THE NORMAL INFANT 269 

which loom ominously before us. Are our combinations those 
best adapted to meet the demands of the body? In years to 
come we may learn that boiled milk has produced some hidden, 
undiscovered damage. We have learned that high carbohy- 
drate, fed exclusively or in combination with high salts, fills the 
tissues with water but does not satisfy their hunger. Some 
evidence shows that children fed with no fat in the diet may at 
times possess a decreased immunity to infection. We may 
learn in time that our moderate reduction of fat, our slight in- 
crease of carbohydrate, though passing the intestine easily and 
safely, may not have been a combination best adapted for the 
body tissues. Only years of study and observation will an- 
swer these questions. The physiologist, Friedenthal, recently 
has devised a mixture in which the salt proportions are identical 
to those of breast milk. In this mixture fat and carbohydrate 
may be given in the same relations as in breast milk, with little 
evidence of intestinal disturbance. This is again a splendid 
step: a means of introducing fat and carbohydrate into the 
tissues in the same proportions as they exist in breast milk, and 
with no danger to the intestinal tract, but is as yet somewhat 
impracticable. 

Until these indications can be met practically and simply; 
until we can introduce to the tissues food-stuffs in the same pro- 
portions as they exist in breast milk without in any way im- 
pairing digestive and assimilative functions, we believe that our 
method of feeding is the most feasible. It is easily employed, 
seems to satisfy the mothers, seems to provide for the growth 
of healthy, thriving, happy babies, who look well and strong and 
appear smiling and contented, and, first and foremost, it answers 
the requirements of simplicity. 



LECTURE IX 
BREAST FEEDING 

I have neglected the subject of breast feeding until now be- 
cause often it becomes necessary to supplement the breast with 
the bottle. If we have mastered the art of prescribing artificial 
mixtures, then difficulties with supplementary feeding will be 
very slight indeed. 

It is not necessary to emphasize the importance of breast 
feeding. You know that breast milk is the natural food. You 
know that the breast-fed infant is more immune to infectious 
disease than is the artificially fed. You know that mortality is 
much less among breast fed than among bottle babies. When- 
ever there is any possibility of offering breast milk, by all means 
do so. 

General contraindications to breast feeding are few. As 
you know, tuberculosis in the mother almost unanimously is 
agreed a distinct one, but even against this some voices have 
been raised. Tubercle bacilli have never definitely been dem- 
onstrated in human milk, and some men claim if the mother, 
during nursing, will protect the baby from her coughing, that 
tuberculosis is a contraindication only from her own standpoint 
and not from that of the child. This, however, is the opinion 
of a few, but I give it to show that even against the most ortho- 
dox of all contraindications objections have been filed. I be- 
lieve, though, that the consensus of opinion makes tuberculosis 
of the mother a contraindication to nursing, not only from her 
own standpoint, but also from that of the child. 

Severe constitutional diseases, such as malignancy and epi- 
lepsy, are, of course, contraindications. 

As regards acute infectious disease, such as typhoid, scarlet, 
diphtheria, etc., opinion, particularly in European clinics, is 
becoming more and more tolerant. The newborn has consider- 

270 



BREAST FEEDING 271 

able immunity to infectious disease. Again, very few patho- 
genic bacteria have been demonstrated in breast milk, and the 
theoretical objection that toxins are excreted may be met with 
the theoretical answer that antitoxins also will pass to the child. 
Even in diphtheria, if the child be properly immunized, breast 
feeding is permitted. 

These opinions of the European men may seem rather radical 
to you. I give them, however, to emphasize the importance in 
which breast feeding is held, and to show that most contraindica- 
tions are those raised in consideration of the mother rather than 
the infant. Even in erysipelas, where a superficial infection of 
the breast makes it possible for organisms to pass to the milk, 
this may be drawn off, boiled, and then offered to the baby. 

Syphilis, as you know, is an indication, rather than a contra- 
indication. Whether the syphilitic woman be mother of an 
apparently well baby, or whether an entirely well woman be 
mother of a syphilitic baby, in all cases we should insist upon 
breast feeding, for in both these conditions we believe that 
mother and child are alike infected. 

Some difficulties arise, however, from local changes in the 
mother's breasts. Perhaps two are important: 

1 . Retracted nipples make much trouble, cause great anxiety 
to the mother, and to considerable extent handicap the nursing. 
In many cases, however, if the mother practises patience, these 
difficulties can be overcome. Instead of surrendering in des- 
pair, simply tell her, " Yes, it's going to be hard for the baby to 
nurse, but if you practise patience and perseverance, after a 
week or two he may learn to take the breast." Patience and 
perseverance are the requisites necessary, and after a week or 
two of conscientious work the mother may be able to educate 
her child to nurse from nipples that previously seemed hopeless. 
Application of a breast-pump between nursing periods aids in 
drawing them out. 

2. Erosions and fissures are extremely disagreeable. By the 
pain inflicted upon the mother they make nursing a very great 
burden indeed. The variety of treatments offered is of itself 
sufficient evidence of the inefficiency of any particular method. 
Medicaments suggested are: 

(a) The use of a cotton swab saturated with 1 to 2 percent 



272 INFANT FEEDING (CHICAGO METHODS) 

silver nitrate solution, and laid upon the fissure for a minute 
once during the day. 

(b) The following prescription of the French is one highly rec- 
ommended by Langstein and Meyer. Personally, I have had 
no experience with it, but I give it upon their recommendation. 
The technic is as follows: Wash the nipple after nursing, and 
apply the following mixture on sterile gauze: 

Tincture of benzoin 12.0 

Sodium borate 8.0 

Glycerin 20.0 

Rose-water 40.0 

Cover with oiled silk or gutta-percha and bandage. Before 
the next nursing wash off with lukewarm boiled water. 

A valuable point in treating these fissures is the use of a mild 
local anesthetic ointment. A 5 percent salve of anesthesin 
applied to the fissures just before nursing is a great relief to the 
mother. Anesthesin is not poisonous to the child, and is very 
acceptable to the mother on account of the relief from the severe 
pain. In order to give the painful nipple as much rest as pos- 
sible, longer feeding intervals should be employed; indeed, one 
might substitute a bottle for one nursing. Nipple-shields too 
are of great value. The very best of these is a large one, made of 
pure rubber, covering almost the entire breast. 

Difficulties with nursing from the standpoint of the child are 
not many. A cleft-palate or harelip is to be considered. These 
handicaps, like the retracted nipple, often can be overcome by 
patient, conscientious work of the mother. Many cases which 
seem hopeless at first, after a week or two of devoted care may 
learn in some way to obtain milk from the breast. 

Other difficulties, such as a neuropathic constitution of the 
child, we shall consider in the next lecture. 

As regards the entrance of milk into the breast, this occurs 
between the first and eighth days — usually about the fourth. 
Often, however, it is delayed, and you are asked by all con- 
cerned, '" Can we hasten it?" 

Gentlemen, there is one, and only one, lactagogue you may 
use with any degree of assurance, and that is the nursing infant. 
The only stimulus to a breast is one arising from this source. 



BREAST FEEDING 273 

Wet-nurses in European clinics sometimes nurse four or five 
babies, and often secrete two to three quarts of milk a day: 
the greater the stimulus to the breast, the greater the response. 
And so, gentlemen, to hasten the entrance of milk into the 
lagging breasts, urge the frequent and regular application of the 
infant. Of course, if the mother believes that any particular 
medicine or any particular drink is going to help her, or does 
help her, by all means don't discourage her. Do anything you 
can to put her mind at ease, and at the same time to keep her 
in the best physical condition. If the baby does not nurse very 
vigorously, you may use a breast-pump also; but this, in con- 
nection with massage, electricity, and all other artificial aids, is 
infinitely less efficient than the normal natural method. 

If, in spite of frequent, regularly repeated applications of the 
babe to the breast, the milk still delays, how long shall we wait? 
Safely, a few days. During this time we must be very careful 
not to entirely appease the baby's appetite with artificial food. 
We must keep him hungry. We want him to tug good and hard 
at the breast, and therefore, during this time, we offer only a 
little water or weak tea. By this method we can accelerate the 
appearance of the milk. However, gentlemen, don't focus your 
attention so carefully upon the mother that you forget the child. 
Don't let your zeal for hunger lead you into the greater error 
of letting the child suffer from too much hunger. In all these 
cases, as I have repeated over and over, our index is the 
baby's weight curve. The physiologic loss of weight during the 
first few days amounts to from one-half to one pound. If the 
child shows no tendency to recover, or if he continues to lose, 
we must heed this danger-signal and direct our attention more 
.to the babe and less to the mother. We must put him to the 
breast more frequently, using both breasts if necessary, or if 
this is impossible, add a bottle to the diet. We must never for 
a moment allow the hunger to develop weakness, for if the child 
becomes too weak to nurse properly, we defeat our own purpose. 

Among the laity the general opinion is that breast milk is 
influenced, as regards quantity and quality, by many different 
factors — by diet, by medication, by nervous influences. As a 
matter of fact, accurate, scientific experiments showing changes 
in breast milk are very few indeed. You must remember that 
18 



274 INFANT FEEDING (CHICAGO METHODS) 

the amount of the individual ingredients secreted during the 
individual nursing varies. Fat is in small amount at the begin- 
ning, and increases toward the end. To get experiments not 
subject to criticism one must analyze twenty-four-hour speci- 
mens of breast milk. 

Experiments which will withstand searching criticism are 
few, but those that have been made suggest that nervous and 
psychic factors, pregnancy and menstruation, positively have 
no effect upon the quality of the breast milk. Undoubtedly 
children show disturbance at such times, particularly during the 
menstrual period, but our present observations tend to show 
that these disturbances are due to changes in quantity rather than 
quality of breast milk. Less milk is secreted, the child is hun- 
gry, becomes peevish, irritable, and fretful, and the natural 
conclusion is that the quality of the milk is changed — that the 
milk is not agreeing with him. As far as we know now, how- 
ever, there is only one definite change, and this usually a dimi- 
nution of the total secretion. 

As regards the influence of diet, we despair more and more. 
No one in experiments devoid of criticism has shown that he can 
control at will the quantity or quality of breast milk by change of 
diet. Many of the statements you read as to the efficiency of 
diet are based upon only the most superficial investigations. 
There is one exception, perhaps, this being with fat. In under- 
fed, badly nourished women, high fat feeding at times seems to 
increase the fat in the milk secreted. There is some doubt, 
however, as to whether this influence is exerted also in well- 
nourished women. Probably it will hold absolutely true only 
in the undernourished. 

We are in the same position as regards medication. Every 
drug in the pharmacopoeia at some time or other has been tried. 
Every one in turn has been given up. The latest is pituitrin. 
This, in definite physiological experiment, will increase the 
amount of milk excreted in a given time, but again must we be 
disappointed. Most recent observations show that it acts upon 
the smooth muscle-fibers, causes them to contract, thus forcing 
the milk more rapidly from the breast, but that it in no way 
affects the total secretion. 

There are two ways by which we may affect the supply of 



BREAST FEEDING 275 

breast milk. Undoubtedly one is by building up the general 
nutrition of the mother — good hygiene, good food, fresh air, 
and plenty of exercise. Many nursing mothers are lax in this 
respect. Besides hygiene, there is the aforesaid suggestion, 
namely, the use of a hungry, healthy, strong child. So much 
difficulty, however, attends this in private practice that it is 
really just as satisfactory to add a supplementary bottle after 
each feeding from the start. 

As a matter of fact, in most disturbances upon the breast the 
following scheme is satisfactory. Make up your mind that 
breast milk is always all right in quality. Make up your mind 
that the only difficulties arising from breast feeding are those of 
quantity. Treat the mother as you will to put her mind at 
rest, but from your own standpoint conduct your treatment 
along the lines of correction of the amount, and if you keep your 
child on four-hour feedings, this correction will be one usually 
for underfeeding, rather than overfeeding. 

You see wiry in relatively well-nourished babies who are not 
gaining on the breast I like to wait a w T eek or so without the 
supplementary bottle. I reason that may be from nervous fac- 
tors or constitutional change there has been a temporary dimi- 
nution in the secretion, and that, after a week or two, this will 
right itself. However, where the condition has lasted longer, 
out of consideration for the child we are justified in no further 
delay. 

Just a few words about the technic of nursing, because errors 
in technic sometimes are responsible for many disturbances. 
Some men would not place the newborn to the breast at all 
during the first twenty-four hours; others would every six 
hours. As long as one keeps up the supply of fluid, these dif- 
ferences in technic are of slight importance. Personally, I 
believe application to the breast is better, as it stimulates secre- 
tion of milk and possibly also uterine contractions. 

Question (by Dr. Summerell of China Grove). — Doctor, have 
you had enough experience in the country to have seen new- 
born pigs? 

Answer. — No; my personal experience in that direction is 
limited. 

Question. — Well, the minute pigs are born they make for the 



276 INFANT FEEDING (CHICAGO METHODS) 

breast and nurse right away. Don't you think it's a good idea 
in our treatment to follow the lead of nature? 

Answer. — Yes, that's an interesting point. I think if we 
physicians had more experience with country life it would be 
better for us. I should consider that observation as valuable 
evidence in favor of putting the child to the breast during the 
first day. 

As regards rigid disinfection of the breasts, our ideas are 
changing more and more. Where the mother practises ordi- 
nary cleanliness, application of strong chemicals to the nipple 
is absolutely uncalled for. Of course, in very poor districts, 
where the breasts are caked with dirt, they must be washed 
thoroughly; but in ordinary private practice cleansing with a 
little cotton and lukewarm water is all that is necessary. If the 
mother be of the modern, scientific type and wishes something 
more fashionable and antiseptic, use a little boric solution. 
Personally, however, I believe the use of strong antiseptics a 
frequent cause of painful, fissured nipples. 

Question by Dr. Summerell. — In the cases of our poor patients, 
where the mother's work keeps her all day long in the fields, 
where underclothing is changed infrequently, and where cloth- 
ing is, of course, saturated with perspiration, where absolutely 
no care of the body is taken before the baby nurses — in such 
cases, doctor, do you advise some sort of application to the 
nipples? 

Answer. — Where the breasts and nipples are dirty, of course 
they should be cleaned, but the best means for this process is 
ordinary soap and water. 

Question. — Do you believe the offensive odor of the clothes 
in such cases would interfere with the baby's appetite or pre- 
dispose to disturbance? 

Answer. — The influence of bad odors and bad air upon a 
nursling's appetite is open to dispute. I believe, however, that 
most men think this influence unimportant. 

How often shall we put the baby to the breast? The same 
rules apply as to the bottle baby. 

How long shall we allow the baby to nurse? Until he is 
satisfied, and this requires from fifteen to twenty minutes. 
The first five are the most important, for in these five the baby 



BREAST FEEDING 277 

gets the greatest amount of milk. You easily can tell, gentle- 
men, when he is satisfied by the cessation of the swallowing 
sound. When he is hungry, he nurses and swallows constantly. 
When he ceases to swallow and lies playing idly with the nipple, 
he has had enough. If he has emptied the breast thoroughly 
and still is not satisfied, we either order an increase in the num- 
ber of feedings or put him to both breasts. But in the latter 
case we must be perfectly sure that the first breast has been 
emptied thoroughly. A child is easily spoiled, and if the second 
breast awaits him, often will not thoroughly empty the first. 
Of course, the reduction of the stimulus will cause reduction of 
the amount of milk secreted. 

One little point of technic often is overlooked — a point of 
considerable value, even though used by our grandmothers. 
You remember our grandmothers used to interrupt the nursing 
at intervals to place the baby so that the abdomen was against 
grandmother's shoulder. Then she would pat him on the back 
until he belched up some air. In the younger days of pediatrics 
any practice interfering with the quiet of nursing was rejected. 
Recently, however, we are learning that there is much truth in 
grandmother's advice. If you hold a baby when nursing in 
front of the fluoroscope, you will see that he frequently swallows 
air. A large bubble collects in the upper part of the stomach. 
This interferes with the proper filling of the stomach, prevents 
his getting sufficient food, often makes him vomit, and may 
cause colic. If you break the nursing interval every few min- 
utes and pat the child upon the back, as our grandmothers did, 
he belches up air, the tension in his stomach is relieved, and he 
nurses with renewed vigor. Many perplexing difficulties with 
breast feeding are overcome by this simple bit of advice. 

In instructing the mother as to nursing, tell her the baby does 
better if he has not only the nipple, but also a little of the areola 
in his mouth. 

How do we know when the baby is doing well — if he is getting 
sufficient food? The best index, gentlemen, is his weight. If 
he gains on an average of about six ounces a week, no fault can 
be found with his nutrition. 

Dr. Summerell asks how often it is advisable to weigh the 
baby as a routine. 



278 INFANT FEEDING (CHICAGO METHODS) 

Answer. — The oftener the better. I should say at the very 
least once or twice a week. 

Dr. Summerell. — That is all right, doctor, but in our country 
practice the parents have no scales. Have you any idea as to 
the feasibility of a portable scales? 

Answer. — One of the men of the Children's Memorial Hospital 
at home (Dr. Spicer)* has devised an ingenious scales. I have 
had no experience with it myself, but from his description it 
sounds quite practicable. 

What shall be the diet of a nursing mother? As far as we 
know the nursing mother may eat absolutely anything that 
makes her happy and contented. We may disregard totally in 
this respect the mandates of our grandmothers. If the nursing 
mother likes vinegar and it agrees with her, let her have it. 
Whatever she craves, whatever she can digest, whatever pleases 
her and makes her happy and contented, she shall have. Our 
sole desire in regulating her diet shall be to fulfil three require- 
ments : 

(a) She must have enough food. Many a poor woman does 
not secrete a good supply of milk because she herself is starving. 

(6) The food must be digestible. The nature of the food de- 
pends upon the mother's social condition and her tastes, but 
anything that she can digest she may eat. 

(c) Lastly, we must gratify her thirst. Langstein and Meyer 
dwell upon this point, which seems to me a very important one. 
The mother normally secretes about a quart of milk a day. 
Thus she excretes almost a quart of water more than normally. 
You see, then, that she has every reason to be thirsty. Here is 
where many mistakes, even by well-educated physicians, are 
made. The physician takes advantage of this thirst to force 
extra food. The mother does not need extra food at this time, — 
her appetite is taking care of that, — but she needs fluid. This 
should be given as water, tea, broth, or thin soup. How wrong 
it is to take advantage of her need of fluid by throwing into her 
body a great excess of starches, such as are contained in thick 
soups and gruels. She does not need this excess of food pro- 
vided she is getting her meals normally : she needs simply water. 

Question by Dr. Gilmer. — Doctor, if a baby is four months old, 
* Amer. Jour. Dis. Children, January, 1915, p. 70. 



BREAST FEEDING 279 

could you offer him milk from a mother of a newborn? What 
is the present idea as regards feeding children milk of a mother 
whose child is so much younger? 

Answer. — As far as we know now, such considerations are im- 
material. Breast milk is the ideal food, and is infinitely better 
than any other food that can be offered, no matter how young 
or old the other baby may be. 



LECTURE X 
DISTURBANCES IN THE BREAST FED 

Gentlemen, disturbances of the breast fed also, we prefer to 
consider as disturbances of nutrition. Just as in the artificially 
fed child, the symptoms arising are many more than those of 
simply local gastro-intestinal irritation. The skin, the nervous 
system, the decreased immunity to infections, above all, the 
weight curve, show that involvement is general. 

Just as in the artificially fed baby, we find vomiting, diarrhea, 
or constipation. When these exert no influence upon the weight 
curve, we are acting wisely if we let the baby alone. However, 
as you once took me to task as regards the practical importance 
of these subjects, just a few words about them. 

VOMITING 

If the babe is brought for vomiting, the first thing to establish 
is the duration of the symptom. Is it an acute attack or has it 
been present for a long time? Acute vomiting may be due to 
infections, enteral or parenteral, may be associated with dis- 
turbances of nutrition or metabolic disorders, may be due to 
nervous factors which are, as yet, not clear to us, and, of course, 
in older children may follow the conventional cucumber-water- 
melon mixture. Often it is due to too much fat. 

Chronic vomiting may be associated with chronic disturbances 
of nutrition, such as decomposition, may occur even in inanition, 
may be associated with a so-called neuropathic constitution 
(which we shall discuss in a moment), and may be due to pyloro- 
spasm or pyloric stenosis. 

Treatment. — In our treatment, however, we must adopt the 
same attitude that we have to the stool. Vomiting is simply a 
symptom and must be made subservient to the condition of the 
baby as a whole. If the baby is gaining; if he is well and happy 
and contented, by all means let him alone. Keep your eyes open 
for errors in technic of nursing, such as overfeeding, irregular 

280 



DISTURBANCES IN THE BREAST FED 281 

feeding, neglect of patting him on the back, and too rapid feed- 
ing; but frequently vomiting persists in spite of perfect and un- 
impeachable routine. If so, the disturbance is due probably 
to the baby, the fault lying with a hyperesthetic mucous mem- 
brane or to faulty reflexes. No matter what be the underlying 
cause, if the bab} r is thriving, if he is happy, contented, and satis- 
fied, take the mother into your confidence : tell her this condition 
occurs so frequently as to be considered almost normal; and 
explain that from the third to the sixth month it will disappear. 

On the other hand, if the baby's nutrition is suffering, we 
must take notice. Acute attacks will disappear upon treat- 
ment of the underlying cause, and require little actual treatment 
of the vomiting except in older children who have devoured im- 
possible food-mixtures. For them a good stomach washing and 
a dose of castor oil will be a cure. 

In the chronic vomiting also we attempt to treat the funda- 
mental cause, as in nutritional disturbances. Pyloric stenosis 
may require operation. The spastic vomiting of neuropaths, 
usually considered a pylorospasm, may be influenced by — - 

(a) Increasing the number of feedings and thus decreasing 
the quantity in each. 

(b) Reduction of the fat, and offering as a substitute Keller's 
Malt Soup or a buttermilk mixture. 

(c) Anesthesin or novocain, 1/60 grain before meals. 

(d) Tincture of belladonna, one or two drops with a few drops 
of paregoric before meals. I have found this very satisfactory. 

(e) Sodium citrate, 1 to 2 percent; one dram in each bottle 
has been recommended by the French. 

Prolonged boiling of the milk for some minutes may be very 
successful. 

But in all cases don't do too much. Sometimes all that is 
necessary is to reduce the total quantity and make up for the 
decrease of food value by an increase in concentration. 



ABNORMAL BOWEL MOVEMENTS 

(a) In reading text-books you learn that the stool of the nor- 
mal breast-fed baby is soft, homogeneous, pasty, yellow, and 
smooth. This undoubtedly is a normal stool. But, gentle- 



282 INFANT FEEDING (CHICAGO METHODS) 

men, if you examine a great number of breast-fed babies you 
find that the stools are green, slightly watery, somewhat acid, 
and contain mucus and curds. These occur more frequently, 
or at any rate fully as frequently, as those described in the text. 
In spite of this apparent abnormality the baby thrives, gains 
persistently, is happy, contented, and satisfied. Under such 
circumstances, why these stools are not to be considered normal 
I do not know. 

The cause of them is not certain. It may be intestinal fer- 
mentation; it may be a neuropathic constitution — probably 
both. But as long as the baby is happy, contented, and gain- 
ing, let him alone, and instruct the mother that this stool is 
absolutely normal. Tell her that it will correct itself by the third 
to sixth month. If it does not, we can be of service in a way 
to be mentioned later. 

(b) Constipation. — In discussing the constipation that occurs 
independent of nutritional disturbance, let me present an idea 
of my own. I present this to you purely as an idea, not as a 
fact — one which you may in your leisure moments consider, 
but not necessarily believe. For my own purpose I divide con- 
stipation into two types: these you probably will not find in 
text-books; but this arbitrary classification has been of great 
value to me. 

(1) The first I call pseudo-constipation. Here the baby is 
perfectly happy, contented, and thriving. Bowel movements 
occur perhaps once in two days. They are normal, soft, and 
homogeneous. The mother complains to you bitterly. She 
has read in her guide book, or has been instructed by the family 
physician, that unless the bowels move once a day the baby 
won't sleep, will be restless, will have colic. As a matter of 
fact, gentlemen, these symptoms exist only in the mother's 
mind. They are in the guide book, or in the advice obtained 
from outside sources, but in the baby they rarely exist. He goes 
sailing along perfectly independent of the anxiety he is causing. 
Has it ever occurred to you to question the authoritj^ which 
states that a baby must have one bowel movement a day? 
Frequently I have asked myself, "By what right has this author 
to state definitely that a child must have a bowel movement 
daily." We do not lay down definite rules as to the frequency of 



DISTURBANCES IN THE BREAST FED 283 

urination. We know that this depends upon many different 
factors. 

The text-books make the statement, but where is their author- 
ity? It comes, I presume, from books written in previous times. 
These books, when written, were founded upon more previous 
observations; and ultimately, I presume, we should find the 
statement, like so many we read, to have originated in those 
medieval, mysterious ages when knowledge was dogma and 
wisdom superstition. In such cases I tell the mother, "For this 
baby this condition is normal; don't worry. The intestine is 
so strong that he is absorbing almost all his food. Very little 
remains in the bowel, and two days are required for residue to 
accumulate sufficiently to cause a normal bowel movement." 
As I say, gentlemen, this idea may be wrong, but it gives good 
practical results. 

(2) True constipation requires more definite treatment. Here 
the stools are hard and soapy; i. e., truly constipated. They 
do not adhere to the diaper, and the baby may strain and have 
pain. No matter how well the child may thrive, if he strains, 
woe be to you if you tell the mother to let him alone! If you 
wish to retain your practice, you must suggest definite therapy. 
How shall we proceed? First, make a careful examination to 
rule out any organic cause, such as tumor or a congenitally di- 
lated colon. Shall we give physics? This is not reasonable. 
Physics simply flush out the bowel but do not correct the funda- 
mental cause. Enemas often do more harm than good. When 
these are repeated daily, the child's rectum becomes sore and he 
voluntarily restrains himself to prevent the pain. Thus we de- 
feat our own purpose. If the mother insists upon active treat- 
ment, an enema of one ounce or more of olive oil may be intro- 
duced into the rectum once or twice a week, just before the baby 
goes to sleep. Instruct the mother to hold the buttocks to- 
gether, so that the oil remains in the intestine all night, and in 
the morning, either spontaneously or from a mild suppository, 
the child will have a soft bowel movement. 

As regards correcting the underlying cause, we must attempt, 
as closely as possible, to simulate the normal. In the intestine 
of the normal breast-fed child a state of mild fermentation exists. 
As you remember from the lectures on artificial feeding, such a 



284 INFANT FEEDING (CHICAGO METHODS) 

condition may easily be produced by the use of fermentable 
carbohydrate. Offer your patient, after each nursing, an ounce 
or more of cereal water with 5 percent to 10 percent lactose, or 
else add from one-half ounce to an ounce after each nursing of a 
10 percent watery solution of malt soup extract. In addition, 
use fruit-juices, and after the third or the fourth month a little 
apple-sauce. With such simple procedure, these cases respond 
readily. 

So much for isolated symptoms where the babe as a whole has 
been unaffected. 

Now for those which affect the weight curve. 



INANITION 

The first of these, as in the artificially fed, we might call 
" failure to gain." In the normal breast fed failure to gain 
almost invariably is due to insufficient milk, and so usually is 
inanition. As regards gastro-intestinal symptoms, the stools 
are of the truly constipated type, being infrequent and hard; 
but, gentlemen, let me urge that in some cases stools are green, 
watery, and contain mucus and curds. No worse mistake can be 
made than diagnosing such cases, as so frequently is done, gas- 
troenteritis from overfeeding. 

Symptoms of general involvement are cessation of the normal 
gain in weight, pallid, inelastic skin, lost agility, and sunken 
abdomen. The nervous system is affected. The child may cry 
continuously, showing neurotic tendencies by scratching the 
skin of the face and body. Crying, however, may be entirely 
absent. 

Dr. Woodson asks: What difference do you draw between 
inanition and decomposition? 

Answer. — That is rather a fine point, but perhaps rather a 
practical one, too. 

Inanition is a condition arising from insufficient food. When 
a child is in a state of inanition, increase his diet and he will 
gain. When, however, the inanition has proceeded to an ex- 
treme degree, then we speak of decomposition. Now if we add 
food to the diet, a paradoxical reaction will result and the weight 
curve goes down. 



DISTURBANCES IN THE BREAST FED 285 

By simple inspection we scarcely can say whether the child 
is in a state of simple inanition or whether this has proceeded to 
a mild decomposition. We can tell only by the reaction to food. 

As a matter of experience, however, children on the breast, 
although they may suffer considerable inanition, rarely proceed 
to decomposition as do bottle babies. It is on the basis of this 
experience, knowing that the breast baby, perhaps due to the 
better condition of his tissues, never proceeds to such a severe 
stage as does the bottle baby, that I am not so careful with 
their bottles in supplementary feedings. 

In the etiology of inanition several factors are to be con- 
sidered : 

(1) Insufficient milk may be due to failure of the supply of 
the mother; to retracted nipples; or to fissured nipples. 

(2) The child may be unable to obtain sufficient milk, due to 
cleft-palate or harelip. What so frequently is overlooked is 
weakness in the child. Small twins or prematures may be 
unable to obtain sufficient nourishment simply from lack of 
strength. 

(3) A so-called neuropathic constitution may be the basis of 
the trouble, resulting in a distracted physician and a perturbed 
household. The mother's breast may be abundantly supplied; 
the slightest pressure may cause milk to gush forth. The child, 
however, when put to the breast, takes one or two swallows, 
then seems to show an absolute lack of interest in anything con- 
nected with his food, and lies disinterestedly playing with the 
nipple. How deceptive is this contentmeDt! Were we guided 
in our feeding solely by the baby's disposition we would com- 
pletely overlook the warning given by the stationary weight 
curve. 

In the newborn this neuropathy manifests itself by some 
difficulty in swallowing. The nervous system is incompletely 
developed, and the child's swallowing reflexes are not as they 
should be. The child makes clumsy, awkward attempts. Dur- 
ing the third or fourth month, however, this constitution shows 
itself in more persistent form; that is, in a prolonged loss of 
appetite. Do what you will, the little fellow takes no interest 
in his food. He smiles and is happy, but will not nurse. In- 
variably the distracted mother insists, "My milk is no good; 



286 INFANT FEEDING (CHICAGO METHODS) 

the baby absolutely refuses it." The unfortunate innocent 
physician gets a wet-nurse. Added to his worries now are not 
only the complaints of the mother, but also the domestic in- 
felicity arising from the new acquisition to the family. The 
baby refuses the breast of the first wet-nurse and she is dis- 
charged. Sometimes four or five are employed before the un- 
happy, by this time well-nigh insane, physician realizes that 
fundamentally the fault did not lie with the breast milk, but did 
lie with the baby. 

4. The failure of the child to gain may in another way be due 
to insufficient breast milk. He may obtain enough, but lose it 
again by vomiting. As a general rule, mild vomiting does not 
produce any marked inanition. The vomiting of the neuro- 
pathic child may be severe, however. It is usually associated 
with a spasm of the pylorus and is spastic in nature. A mother 
in one of our poorer districts described it best to me by saying, 
"John vomits the way his pa spits tobacco." In this and in 
true stenosis of the pylorus, disturbance is grave and severe. 

5. Lastly, and not to be classified as inanition, failure to gain 
may be a temporary affair, resulting from an acute dyspepsia. 

Diagnosis. — First, is this a case of inanition, or if the stools be 
dyspeptic, is it a case of overfeeding? Instead of wasting time 
speculating, simply weigh the baby for a twenty-four-hour 
period before and after each nursing, and estimate the day's 
total intake. This simple procedure rather than stool exami- 
nation makes a definite diagnosis. 

Equally important is it to diagnose the cause. Retracted or 
fissured nipples speak for themselves. If the fault be an in- 
sufficient supply, the baby, after five or ten minutes, ceases 
nursing and cries irritably. Examination of the breast shows 
it to be empty, or if the nursing be interrupted, one finds that 
the milk oozes from the nipple simply drop by drop. 

If the fault lies with the child, observation of the nursing 
process makes the diagnoses. The clumsy swallowing of the 
newborn points to undeveloped reflexes. The lack of interest 
in the older child shows the neuropathic loss of appetite. 

Vomiting is recognized by the history and the examination. 

Prognosis. — In the breast-fed this is relatively good. Rarely 
does the breast-fed child progress to the stage of decomposition 



DISTURBANCES IN THE BREAST FED 287 

so easily reached by the bottle baby. Decomposition results 
only in extreme cases. 

Treatment. — Treatment depends upon the cause, (1) If the 
fault lies with insufficient milk, the child may be put to the 
breast more frequently or else both breasts may be used. If the 
weight curve does not rise after a few days of this treatment, a 
bottle may be added after each nursing, the amount depending 
upon the amount of milk obtained from the breast. As children 
wean themselves rapidly, never give the child the bottle until 
the breast has been thoroughly emptied. 

(2) When the fault lies with the child : 

(a) If it be due to the undeveloped reflexes of the newborn, 
we must be patient for a few weeks. However, during this 
time don't allow the baby's nutrition to suffer; and insist that 
the breast be emptied after each nursing, so that the supply does 
not fail. 

(b) If the fault lies with loss of appetite, correction is more 
difficult. Sometimes a few drops of pepsin with dilute hy- 
drochloric acid, given before each meal, stimulate the appetite. 
A daily stomach washing may be of value. A lukewarm bath, 
followed by a cool spray, occasionally gives striking results. 
In the latter be careful not to shock the child. Babies are very 
susceptible to cold. Make the spray just cool enough to be 
mildly stimulating and to make the child breathe deeply; to 
make him cry perhaps, but under no circumstances to shock 
him severely. If this is done once or twice a day, a few minutes 
before meal-times, often the child nurses with considerably more 
vigor. 

During this period of treatment the child's nutrition must by 
no means be neglected. Here great errors are made. The 
physician too frequently says, "If this child won't nurse, we'll 
let him get so hungry that he will have to." Such treatment 
accomplishes nothing. The child's loss of appetite is not due 
to his having obtained sufficient food. It is due to the con- 
dition of his nervous system. Whether you give food more 
frequently or less frequently, his appetite will not change unless 
the underlying fault can be corrected. Under these circum- 
stances, as the baby takes only the slightest amount of food at 
each nursing, put him to the breast oftener, and then, if his 



288 INFANT FEEDING (CHICAGO METHODS) 

weight curve doesn't ascend, use forced feeding, because there 
is no reason for his nutrition's suffering during the period that 
you are trying to overcome his nervous tendencies. The use of 
a stomach-tube may accomplish a marvelous cure. Lastly, 
as this neuropathy is inherited from nervous parents, as the 
baby makes the mother nervous, and the mother in turn makes 
the baby nervous, at times the only thing we can do is to order a 
change of environment. If you can get a good wet-nurse, a 
sane woman who takes a perfectly disinterested sort of interest 
in the child, results are very gratifying. 

(3) In all cases, no matter what be the cause of the inanition, 
don't neglect the child's water supply. Children suffer griev- 
ously from lack of water. In getting small quantities of breast 
milk naturally they reduce markedly their water intake. In 
your treatment don't neglect to make up this deficiency. 

The other marked disturbance is dyspepsia, which is much 
like that arising on the bottle. 



DYSPEPSIA 

Gastro-intestinal symptoms are vomiting, regurgitation, diar- 
rhea, anorexia, flatulence, tympanites, and colic. 

General symptoms other than gastro-intestinal are cessation 
of gain, change in the quality of the skin, slight fever, nervous 
reactions, as sleeplessness and unrest, and decreased immunity 
to infection. 

Etiology. — Several factors may be concerned : 
(1) Alimentary influences up to the present have been con- 
sidered most important. 
Alimentary Influences. — (a) Overfeeding is given the 
first place. Gentlemen, I don't want to be too radi- 
cal, but I believe that more and more we are beginning 
to doubt the importance of overfeeding. As the im- 
portance of constitution grows in our mind, as we recog- 
nize the neuropathic type of child and other types, 
too, as we recognize fundamental differences in the 
baby himself, just so much are we decreasing our 
emphasis on the outside factors. Irregularity of feed- 



DISTURBANCES IN THE BREAST FED 289 

ing in our mind is perhaps much more important 
• than is overfeeding, and let me remind you that ir- 
regularity of feeding is due frequently to underfeeding 
rather than to overfeeding. Indeed, we are beginning 
to doubt whether many cases do result from over- 
feeding. So great is the adaptability of the mother's 
breast to the baby's demands, — when the baby wants 
more, more milk is secreted; when the baby wants 
less, less is secreted, — so great is this adaptability that 
if the child be nursed regularly every four hours it is 
a question whether many mothers can overfeed their 
babies. Perhaps overfeeding is a factor when an 
undernourished infant is put to the breast of a fine, 
healthy wet-nurse. Before the baby has adapted it- 
self to the breast, and vice versa, often too much milk 
is taken. 
Such statements are, of course, heresy, gentlemen, but 
weigh the baby before and after nursing and see for 
yourselves. 

(b) Of alimentary factors, we believe irregularity of 
nursing to be most important, but don't forget inani- 
tion may produce a picture identical to dyspepsia. 

(c) Foreign substances secreted in breast milk and 
causing this dyspepsia we believe very rare indeed. 

(d) Shifting proportions of the different elements, as, 
for example, too much fat, are described. Undoubt- 
edly some breast milk contains more fat than the 
average. As the stools of many of these children, 
however, are typically fermentative, frequently do I 
wonder whether perhaps too much sugar is not being 
secreted. In all cases very little scientific evidence 
proves that disturbances arise from these sources. We 
may learn more later. As I mentioned in our last 
lecture, one will make fewest grave errors if, for the 
present, he considers that invariably breast milk is 
perfect in quality and disturbances are due only to 
changes in quantity. 

(2) Infections. — The more dyspepsias we see on the breast, 

the more do we realize the fundamental influence of in- 
19 



290 INFANT FEEDING (CHICAGO METHODS) 

fection. A baby has been thriving, becomes infected 
with a nasopharyngitis, a bronchitis, an otitis, or a 
cystitis, and a dyspepsia results. When the infection 
has run its course, the intestinal tract corrects itself, 
fermentation ceases, and the stools become normal. 
In this type, frequent errors are made. The mother 
says the milk is not agreeing with the baby. The 
physician may prescribe a wet-nurse; may take the 
baby from the breast; may order medicine for the 
child; may diet the mother; and in spite of all treat- 
ment, improvement occurs. Why? Improvement 
does not result from the therapy; it occurs because 
the child has recovered from the infection. In all 
cases of dyspepsia on the breast don't neglect search- 
ing for parenteral infections. 
(3) Our old enemies, overclothing, overheating, improper care, 

over cooling, are, of course, never to be overlooked. 
The symptoms depend to some extent upon the cause. Those 
due to alimentary factors develop gradually. Nervous changes, 
with disturbed sleep and restlessness, manifest themselves first. 
Later symptoms of the gastro-intestinal tract develop. General 
symptoms and fever are, as a rule, not severe. The type due to 
infection appears rather suddenly in the previously thriving 
child. General symptoms and fever are more in evidence than 
in the former. 

The severity of the reaction and the course depend upon the 
child's constitution — the better the constitution, the less the 
reaction. The alimentary type is progressive and often ends in 
anorexia. The infectious type is short and ends in a cure, with 
recovery from the infection. 

Diagnosis. — The diagnosis is made from the history. 
Treatment. — The treatment is relatively easy where ali- 
mentary factors can be corrected. Where infection is the basis 
of the disturbance, wait. In all cases, and in that mentioned 
at the beginning of the lecture, powdered casein is of value. 
Formerly this could be obtained as a powder. Since the war I 
doubt if it is obtainable, but we may make it by getting the 
curds of milk and putting them through a sieve. You remember 
that casein makes the intestine alkaline, and as most of these 



DISTURBANCES IN THE BREAST FED 291 

diarrheas are of a fermentative nature, casein is ideally suited to 
our requirements. Give it in doses of one or two teaspoonfuls 
after each nursing, and increase until you obtain the desired 
results. Albumin milk may work wonders in small doses after 
nursing. 

One must never neglect the general care of the child, and in- 
quire earnestly into the conditions in the household, clothing, 
and general hygiene. 

One danger leads to serious complications. The mother or the 
physician, not recognizing that an infection is the cause, lays 
great emphasis upon the importance of the breast milk. Some- 
thing must have affected its quality. Therefore we take the 
baby from the breast and starve him until the milk has corrected 
itself and until the stools become normal. Gentlemen, all 
that we have accomplished is to add to our patient's troubles 
the damaging influence of hunger. Frequently he gets better 
with this treatment, but this change is due to cessation of the 
infection. Don't make unnecessary use of hunger. Children 
have so much intelligence, — often so much more than we, — if 
you weigh the baby before and after nursing you will find that 
instinctively he cuts down his diet. You will find that he 
drinks far less during these few days than ordinarily. It is my 
custom simply to put the child to the breast, allow him an in- 
terval shorter than usual, — five minutes, for example, — and to 
repeat this at the regular feeding time, but never let him hunger 
markedly. By this procedure you will find that during these 
few trying days the baby's general nutrition is maintained. 

From the above you see how unnecessary in many cases is a 
wet-nurse. The fault lies so frequently with the baby, rather 
than with the milk, so frequently with outside factors, such as 
infections, rather than with the mother herself. 

Just one word about severe diarrheas occurring in the breast 
fed. Breast-fed children, rarely it is true, but still definitely, 
do develop symptoms almost identical to the alimentary in- 
toxication of the bottle baby. Our previous ideas were that a 
toxin was secreted by the breast milk. I believe this has been 
disproved. I doubt if people ever find human breast milk 
definitely poisonous to the child. However, we are learning to 
recognize other factors. We are learning that parenteral in- 



292 INFANT FEEDING (CHICAGO METHODS) 

fections; true intestinal infections, such as dysentery; or over- 
heating may be the basis of the trouble, and, lastly, we have 
learned that children in states of severe decomposition, when 
given large quantities of any breast milk whatsoever, go down 
and die with the severest alimentary symptoms. 

The treatment is identical to that of the alimentary intoxica- 
tion or true infections of the artificially fed. 

This finishes, gentlemen, infant feeding. There are many, 
many more phases of this interesting subject which I should 
like to discuss with you. Time, however, forbids. If you have 
followed me carefully you will perhaps have obtained some idea 
of the methods of our Middle West, as I understand them. 
I do not urge these exclusively upon you. I trust that you have 
become interested and will investigate the teachings of the great 
men all over this country of ours. After you have obtained a 
comprehensive view of the whole field, select the method which 
pleases you most, or, better yet, you may be in a position to 
select from the different teachings many points of value, and I 
trust that you will use them all, no matter what their source, to 
aid sick and suffering children. 



CLINICS 



CLINIC I 



Gentlemen, I asked you to bring normal babies to the clinic 
today for two reasons: First, no satisfactory work in infant 
feeding can be accomplished without a thorough understanding 
of the normal infant, who represents the ideal for which we are 
striving. Second, you have learned that from the viewpoint 
of infant feeding it is wiser to consider the artificially fed baby 
as a sick baby. For this reason, no matter how well he may 
seem, before you prescribe feedings you must obtain an accurate 
history and a careful physical examination. 

(Normal children are brought by Dr. J. W. Long (Greens- 
boro), Dr. F. Raymond Taylor (High Point), and Miss Powers 
(Winston-Salem). 

Dr. Long's patient demonstrated. 

Gentlemen, just step up and feel the texture of this skin. 
Put your hand on it and notice its delicacy, its velvety softness. 
The first touch, more than the first glance, diagnoses the breast- 
fed baby. Notice the fineness, the elasticity, and the fullness. 
Note the smoothness, the splendid state of nutrition, the delicate 
pink color. Feel the subcutaneous tissue. Strange that the 
first thing we see in looking at any patient is the skin, and yet 
in our examination it's the most neglected of all organs. In 
future clinics we shall learn what marked changes in elasticity, 
fullness, softness, and color it undergoes during the development 
of disturbances of nutrition. Indeed, with eyes blindfolded — 
practically by palpation — we can diagnose such disturbances. 

In this normal baby notice the well-developed muscles — their 
normal tone, neither too rigid nor too flaccid. Note the abdo- 
men, not retracted, not bulging, just about the level of the 
thorax. We haven't this baby's weight, but he looks approxi- 
mately 16 to 18 pounds, which would be normal for a baby of 
about six months. 

Above all things, notice his contentment, his happy smile, 

293 



294 



INFANT FEEDING (CHICAGO METHODS) 



his fearlessness. Note how he reaches for my watch and wants 
to play (Figs. 32 and 33). 







Fig. 32. 



Fig. 33. 



r 1 




Fig. 34. 



clinics 295 

Note how joyfully he stamps and kicks and waves his arms. 
I clap my hands ; he looks at me with a somewhat inquisitive, 
rather pained expression; he's disappointed in me; but he's 
normal (Fig. 34). He doesn't shriek with terror as would a baby 
with a neuropathic constitution. 

Having satisfied ourselves as to the state of his nutrition, we 
ask, "Has he developed normally?" 

I see by Dr. Long's expression that he thinks we have abused 
his protege sufficiently; so let's persecute this one of Dr. Tay- 
lor's. I wish you gentlemen would come up and examine him, 
and then go to your seats and write on a slip of paper your esti- 
mate of his age. 

Well, for such a superficial examination, you have done better 
than you deserve. 

In estimating a child's age, you must take into consideration 
many points. We reason as follows: First, is he a newborn? 

No. The skin has not the characteristic bright-red color of 
an Apache Indian; it is not covered with vernix caseosa, and 
baby's size, of course, contradicts such an assumption. Again, 
the skin of the newborn desquamates for about ten days. This 
skin shows no trace of desquamation. The breasts in all normal 
children secrete during the first week, sometimes a few days 
longer. When these breasts are compressed, no trace of fluid 
exudes. Again, in normal babies the cord falls off within four 
days. In this child not only has the cord disappeared, but the 
navel has also healed perfectly. This shows him to be over 
three weeks. 

Has he reached the normal development of a child of two to 
three months? 

Question. — Mother, does he recognize you? Does he smile 
when he sees you? We don't need an answer. That smile 
speaks for itself. 

Question. — Does he notice things? We'll try him. See how 
the eyes follow my flashlight! See the interest he takes! He 
follows not only with the eyes, but with the whole head. All 
this confirms our opinion that he is at least two to three months 
of age. Interesting, is it not, that when a baby first starts to 
notice external affairs he follows with only one eye, and so dur- 
ing the first four to eight weeks strabismus is normal? By the 



296 



INFANT FEEDING (CHICAGO METHODS) 



end of the second month, however, he follows with both, and 
with the head too. So this baby easily has passed eight weeks 
(Figs. 35 and 36). 






■~j0% 



- 



^ ,-; ya; 





Fig. 35. 



1 


V 

<0 






■4 

r- «• 

- 
/ 

/ 1 


1 V* 

1 \ 1 



Fig. 36 



clinics 297 

Is he over three months of age? 

Does he hold up his head? 

He does this very well, either when raised by the shoulders 
from the table or when lying on his stomach. So he is three 
months or more. At three months tears appear for the first 
time, as does drooling, and coordinate movements of the ex- 
tremities show a beginning of voluntary muscular control. 

Question. — Mother, does he recognize familiar noises? 

Answer. — Yes, he knows my voice and also his father's. 

That shows he must be four months or more. 

Does he sit up yet? Well, he's making a brave attempt, 
but I guess it's too heroic a task. And he has no teeth either. 
At six months a baby begins to sit up, shows two lower central 
incisors, and has doubled his birth weight. From this child's 
size he must be almost six months. But he doesn't sit up, and 
so I judge him to be perhaps five months, or a little more. 

Question. — Is that right, mother? 

Answer. — (Proudly.) He is four months and three weeks. 

Well, here we have not only a baby normal in every respect, 
but also one who is a little ahead of time; so, mother, you may 
be proud of him. 

It will be very interesting to watch the development of this 
young man. When he reaches the dignified age of nine months, 
if supported, he will attempt to stand, and his vocabulary will 
include such choice words as "pa," "ma," and "goo." Nine 
to twelve months may find him attempting to walk. At the 
end of the first year he will treble his birth weight and will have 
six to eight teeth. The large anterior fontanel will close be- 
tween twelve and eighteen months. The posterior, as you know, 
is closed at or shortly after birth. 

You may wonder what all this has to do with infant feeding. 
Simply this: If the baby is not normal as regards his physical 
and mental development, you must make allowance in your 
formulas. If you limit yourselves to rules and regulations which 
concern themselves only with baby's age or his weight, you will 
meet with unavoidable failure. Baby's tolerance to food is the 
vital factor, and this you estimate by careful history and by con- 
scientious physical examination. As a rule, the more deficient 
the child's physical development, the less will be his tolerance. 



298 INFANT FEEDING (CHICAGO METHODS) 

If we do our work thoroughly, we should examine every nor- 
mal baby as carefully as we do a sick one. Time prevents this 
morning, but, nevertheless, I am going to take just a moment to 
examine the heart. I advise you in all cases, in addition to 
general inspection, no matter how healthy or normally devel- 
oped the child may seem, never to neglect this. You will find 
congenital heart lesions not uncommon, and from my own ex- 
perience I believe more and more that these lesions are impor- 
tant factors in influencing the baby's nutrition and predisposing 
him to disturbances. 

I think we have abused this child's good nature sufficiently. 

Let's see the next. 



CLINIC I.— BABY 1 
Brought by Dr. W. T. Meadows (Greensboro) 

Question. — Doctor, is this baby to be demonstrated as a well 
baby or as a sick one? 

Answer. — He has been breast fed until the present, and up to 
three weeks ago had been doing nicely. Since then he's not 
been thriving. I saw him for the first time yesterday, and sug- 
gested that the mother bring him to the clinic. 

Discussion. — Good! Here then we can demonstrate the 
methods of history taking. I'll go over this one in detail to 
show the procedure. After this I'm going to ask you gentlemen 
to take these histories in advance, so as to save time. Before 
starting, however, let me impress upon you that in all our work 
we are going to adopt the attitude of the pediatrician, the chil- 
dren's specialist, rather than that of the general practitioner. 
We are not simply going to say, " What's the matter with this 
baby?" and offer a little medication, but we must use every 
means at our disposal to find out with "just what sort" of child 
we are dealing. We cannot hope for success in our feeding 
unless we know something of the general make-up of our patient, 
and this knowledge we obtain first by careful history, and sec- 
ond by conscientious physical examination. 

Question. — Doctor, will you please take this card and fill it 
out as follows: On the upper left-hand corner write the baby's 
name; on the upper right, his age. 



clinics 299 

Question. — Mother, how old is the baby? 

Answer. — Just four months and one week. 

The first questions in this history are those concerning the 
family. The influence of heredity must never be overlooked. 
Doctor, will you kindly write: 

Family History. — Question. — Mother, are you in good health? 

Answer. — Yes; I didn't feel very strong just before the baby 
came, but I'm all right now. I'm always pretty well. 

Question. — Is the baby's father in good health? 

Answer. — Yes, he's never been very sick in his life except once. 

Question. — What did he have? 

Answer. — Typhoid fever. 

Question. — Are there any nervous sicknesses in your family? 
Have any relatives — your father, mother, brothers, or sisters, or 
your husband's brothers and sisters or parents — ever been in any 
institution for any nervous sickness? 

Answer. — No; there have been no such sicknesses in the 
family, or at any rate none that I know of. 

Discussion. — The reason I asked this is that many children 
•are predisposed to nervous trouble by heredity. It's hardly 
necessary to mention that severe nervous disease, or alcoholism 
in the parents, often leads to epilepsy or nervous degeneracy in 
the child, and this latter, in its turn, frequently gives rise to 
nutritional disturbance. 

Question. — Have you or your husband, or any of your rela- 
tives, or any of your husband's relatives, ever had any lung 
sickness? 

Answer. — There has been no severe lung sickness in our fam- 
ily. Both my husband and I at times have had severe coughs, 
but they have been of short duration, and the doctor said they 
were simple bronchitis. 

Discussion. — We are particularly interested in lung diseases 
because we know tuberculosis in the parent is a frequent cause 
of feeble, poorly developed offspring, and, secondly, even though 
these children may not be born with tuberculosis, in such an 
environment they readily become infected. Of course, tubercu- 
losis is a great factor in predisposing to nutritional disturbance. 

The next points to be considered in the family history are the 



300 INFANT FEEDING (CHICAGO METHODS) 

number of children, the health of these children, and the num- 
ber of miscarriages. 

Question. — How many children have you? 

Answer. — This is the only one. 

Discussion. — Gentlemen, look out. Keep your eyes open for 
the only child; he's always exceedingly difficult to examine. 
Usually — excuse me, mother — he's just a little bit spoiled. He 
likes his own way, and looks upon the doctor as a decided enemy. 
See! He's preparing for the battle. We must handle him with 
great care and discretion. 

Question. — Have you lost any children? 

Answer. — I lost two of colitis. 

Question. — How old were they? 

Answer. — One was nine months and one two years. 

Question. — Have you had any miscarriages? 

Answer. — None. 

Discussion. — We're glad to know that, because miscarriages 
make us at any rate think of syphilis. By no means has every 
mother who suffers from miscarriage syphilis, but if we should 
get a history of miscarriages as follows : for instance, one, say, 
at four months, another one a little later, say, at six months, 
a third one a little later, for example, at eight months, and then 
perhaps a baby born dead, we are justified in being very sus- 
picious of congenital syphilis, and, as I tried to emphasize be- 
fore, in infant feeding we must try to keep our eyes open for 
every influence that possibly can have been exerted upon the 
baby. 

This child seems to have a perfect family history. Nothing 
from this standpoint will influence our feeding orders. We next 
ask if any factors in his past life are of importance. 

Past History. — Question. — Mother, were you well before the 
baby was born? 

Answer. — I suffered from headaches and backache and felt a 
little weak, but never had any serious complaint. 

Question. — No kidney trouble or convulsions? 

Answer. — No. 

Question. — Is this a full-term baby, or did he come too soon? 

Answer. — He was full-term. 

Discussion. — We are interested in knowing this because pre- 



CLINICS 301 

matures are far more susceptible to nutritional disturbances 
than are full-term babies, and must be handled with special 
care. Of particular importance is the next subject: 

Question. — Was the labor difficult? Was there any serious 
complication? Was it necessary to use any instruments? 

Answer. — The doctor told me my case was normal. 

Question. — Did the baby cry as soon as he was born, or did 
the doctor have any trouble with him? Did the doctor tell you 
that he was suffocated, or blue, or that he was almost like dead? 

Answer. — No, he cried right away and seemed all right. Dr. 
Brown said he was a fine baby. 

Discussion. — These are important questions. I ask about 
difficult labor and about instruments because these complica- 
tions may cause direct cranial injury with a resulting menin- 
geal hemorrhage, or by producing a great rise in blood-pressure 
from asphyxia may indirectly cause the hemorrhage. Such 
a hemorrhage injures the brain. As a result, the child does 
not develop properly, and although he may show no marked 
symptoms at first, by the time he reaches five or six months of 
age he presents a grave and most distressing picture. He is 
very backward, his mentality is deficient, his limbs are rigid, and 
often crossed like scissors. In the clinics which are to come I 
haven't the slightest doubt that we shall see such cases of so- 
called Little's disease, and you will learn how this condition 
affects the general nutrition of the child. Children with mental 
defects are very difficult to feed, and many of them suffer ex- 
treme inanition from loss of appetite. 

Question. — How much did he weigh at birth? 

Answer. — We had no scales at home, but Dr. Brown esti- 
mated him at 11 pounds. 

Discussion. — He certainly was a fine youngster. Most babies 
average about 6 to 8 pounds at birth. 

Answer. — All our North Carolina babies are larger than that. 

Question. — What sicknesses has the baby had? 

Answer. — He's had nothing but an occasional cold. 

Question. — Has he ever had measles or whooping-cough? 

Answer. — No. 

Question. — Does he get very sick with these colds? 

Answer. — No. He doesn't get sick at all. 



302 INFANT FEEDING (CHICAGO METHODS) 

Discussion. — In this way we learn first the diseases which 
have influenced this child's life. We are particularly interested 
in measles and pertussis because they so often predispose to 
tuberculosis. Secondly, we learn the nature of his resistance. 
The better the condition of nutrition, as a rule, the more perfect 
is the resistance. 

Question. — Has the child developed in the right way? 

Discussion. — This is hardly a question that mother can 
answer. We can learn this more satisfactorily in our examina- 
tion. Inspection of this apparently normal baby and the his- 
tory of the well-developed resistance to infection make us think 
that he either has been breast fed or has been fed perfectly on 
the bottle. This brings us to the subject of feeding. 

Feeding History. — Question. — How has the baby been fed? 

Answer. — He has been breast fed up to the present. 

Question. — How often have you been nursing him? 

Answer. — I was giving him the breast every two or three 
hours. 

Question. — Was he satisfied with it? Was he gaining? 

Answer. — He seemed going nicely until about two or three 
weeks ago. For the last two weeks, however, he has been pee- 
vish and irritable. He hasn't been gaining, and has been very 
constipated. He won't take the breast any more, and I've 
given him a little sugar water between meals. He likes that 
pretty well, but he vomits a lot. 

Question. — How often do his bowels move? 

Answer. — Well, they don't move every day unless I give him 
an injection. 

Question. — When they move, are they hard or soft? 

Answer. — They are usually soft. 

Question. — Let's see if this is correct. Here is a baby who 
was well up to some weeks ago. Then he became cross, irri- 
table, constipated, stopped gaining, didn't nurse as well as 
previously, and didn't seem contented. Is that right, mother? 

Answer. — Yes. 

Discussion. — Now, gentlemen, following the feeding history, 
we take the present complaint to learn if the child has been 
feverish, has been coughing, sneezing, or showing any other 
abnormal symptoms. 



CLINICS 303 

Present Complaint. — In this case the feeding history probably 
will be synonymous with the present complaint. 

Question. — Does he show any other symptoms, like fever, or 
have you noticed anything else the matter with him? 

Answer. — No, that is all we noticed. 

Physical Examination. — Question. — Mrs. Peck, what is the 
baby's weight? 

Answer. — Eleven pounds two ounces. Temperature, 98° F. 

Discussion. — This would be a good weight for a baby who 
weighed six or seven pounds at birth. But if he weighed almost 
eleven pounds he certainly hasn't gained very much. 

Gentlemen, I'm going to examine him very carefully to show 
the methods. No matter how convinced we are tl\at it's simply 
a feeding case, we never should establish a diagnosis before 
making a thorough examination. We must rule out every other 
possibility and arrive at feeding more by exclusion than in any 
other w r ay. 

Always remember, before confining yourself to any local 
examination, to look at the baby as a whole. Here we see a 
fairly nourished infant. He doesn't look so very sick; he 
doesn't look unhappy — you notice he smiles at us, but the smile 
is a little feeble. Notice this somewhat flabby, inelastic skin; 
the color, too, isn't that of the normal children we just have 
examined; it has the slight muddy tinge which we know to be 
an important symptom. I pick it up and it wrinkles rather 
easily. It seems softer than the skin of the other children. 
The subcutaneous tissue is less firm and allows the skin unusual 
motility. Notice the lack of tone of the muscles. They feel 
flabby. All these findings are suggestive of a disturbance of 
nutrition. 

As a routine, however, we examine every part of the body. 
The osseous system, you know, is very important in infants. 
We feel the large fontanel, which, of course, is widely open, but 
it's neither sunken nor under tension. We feel for softness in 
the bones behind the ears — craniotabes. We find none. We 
feel for beading of the ribs where they join the sternum — the 
rosary. This, too, is absent. Both of these symptoms are very 
suggestive of rickets. As a routine, we examine all the lymph- 
nodes — the cervical, the axillary, the cubital, and the inguinal. 



304 INFANT FEEDING (CHICAGO METHODS) 

We find nothing except a few the size of a pea in the posterior 
portion of the neck. The more children we examine, the less 
significance we lay upon a few palpable nodes. 

Next we seek abnormalities about the head. The eyes, ears, 
and nose show nothing. Everything is normal. You notice 
we let the mouth and throat go for the present, because this child 
is so good we don't want to make him cry. It's a good routine 
to leave the mouth and throat examination for the last. 

We feel for rigidity of the neck — it's absent. We carefully 
percuss the heart and lungs and auscultate. Everything is nega- 
tive. We feel for an enlarged liver and spleen. The flaccidity 
of the abdominal muscles makes this easy. I don't feel the 
spleen. The liver reaches one finger below the costal margin. 
This is of no significance. There are no other abnormalities. 
We examine the reflexes — the triceps, knee-jerk, Achilles, and 
abdominal reflexes. They are all brisk, equal, and show no 
definite findings. So in this case our physical examination is 
absolutely negative. 

Gentlemen, by no means does this finish the examination. 
In every case where anything in the family history makes us 
in any way suspect lues we never must be satisfied until we have 
a Wassermann, and that means a Wassermann on the mother 
as well as the baby. The Wassermann of the parent is perhaps 
the more accurate. 

Again, where the child in any way has been exposed to tu- 
berculosis, we must demand a Von Pirquet test. Where anything, 
such as extreme pallor or enlarged spleen, suggests blood dis- 
eases, we examine the blood, and the stool for hook-worm, and, 
of course, as a matter of routine, where there is the slightest 
suggestion of trouble, or even the slightest possibility, never 
omit a urinalysis. Cystitis is very common, but frequently 
overlooked. 

As to methods of obtaining urine. In a boy it is simple. 
Simply attach a bottle or rubber glove with adhesive. In a 
little girl it's more difficult. Sometimes a cool bath will be 
followed by urination. An enema often causes the child to 
pass water, but, of course, this may be mixed with the stool. 
Letting the child sit upon something cold, as a saucer or plate, 
may cause her to urinate. Massage over the bladder is fre- 



CLINICS 305 

quently successful. A rubber glove may be used. An in- 
genious apparatus by Dr. James Leach, one of the fellows at 
our hospital (Fig. 37). 



V/"^""" * End View 

Nipple Shaped for 
Glass Tubing Application 

Fig. 37. 

This device consists of a rubber nipple from a nursing bottle, 
a suitably curved piece of glass tubing, about three feet of soft 
rubber tubing, and some adhesive plaster. 

The nipple, preferably an old discarded one, because of its 
softness, is cut curved, forming a concave end, with the lower 
portion forming a tongue-shaped cup. The other end is fastened 
to the glass tubing. This tubing is curved so as to fit between 
the thighs, and rests on the bed, preventing dragging, forming a 
ready exit for the urine, and preventing backing up and leakage. 
The rubber tubing carries the urine to a receptacle attached at 
the side of the bed, and the whole is held in place by means of 
adhesive plaster. 

In applying the apparatus the labia majora are retracted, 
the lower cup-shaped portion is applied just within the fourchet, 
and the rest is brought up, inclosing the labia minora and ure- 
thral orifice within the nipple. The labia majora are then 
closed over this and held together with adhesive plaster. The 
whole device is further secured to the vulva by means of a flange- 
shaped piece of adhesive wrapped around glass tubing. 

Diagnosis. — Time, this morning, prevents our going into an 
extensive discussion of the diagnosis. I believe the great ma- 
jority of men will tell you that babies fed ever} r two to three 
hours are suffering from overfeeding. Personally, as regards 
this point, I am somewhat of a heretic. . Understand, however, 
20 



306 INFANT FEEDING (CHICAGO METHODS) 

that many pediatricians will not agree with what I'm about to 
tell you. I believe, nevertheless, that many children who are 
nursed every two to three hours really are underfed. I believe 
that they are nursed so frequently because the mother hasn't 
sufficient breast milk, and tries to ease the child's discomfort 
by placing him more frequently to the breast. I believe, in 
these cases, if we add food rather than reduce it, we get better 
results. The first thing, however, is to determine definitely 
whether the child is receiving too little or too much,. The his- 
tory of discomfort, the failure to gain, the constipation, the 
refusal of the child to take the breast, all point to insufficiency 
of the supply of milk, and we make a tentative diagnosis of 
inanition. 

Treatment. — Mother, I wish you would place this baby to the 
breast regularly every three hours — seven times in twenty-four 
hours: First at 6 o'clock in the morning, then at 9, 12, 3, 6, 9, 
and once during the night. If the baby won't nurse, give him 
absolutely nothing until the next nursing time. Let him nurse 
for twenty minutes. Under no circumstances give him any 
more sugar water. Bring him back to us next week. We'll 
weigh him accurately, and then shall know just exactly what he 
is doing on your breast milk. Be very careful to give him 
nothing in addition to the breast, and be absolutely sure to 
come next week. Good-by! 

Discussion. — Gentlemen, in private practice we wouldn't 
wait so long for the reaction, — that we could determine within a 
few days, — but as these clinics are held only once a week, I 
think it will be desirable to wait to demonstrate the changes. 
I feel quite confident that this baby will not gain and that we 
shall have to add something to the diet in addition to the breast 
milk. In all children who are to come we necessarily must wait 
one week for the reaction, but remember, in private practice 
don't wait over two or three days. 

CLINIC II.— BABY 1 

Age. — Four months two weeks. 

Mother says the baby is no better. He frets after each nurs- 
ing, seems peevish all the time, and very hungry. He suffers 
greatly with colic and is constipated. 



CLINICS 307 

Question. — After he has finished nursing does he still fret? 

Answer. — Yes; he never seems satisfied at the breast, and 
I have a terrible time making him wait until the full three hours 
are up, but when he gets to the breast he doesn't like it. 

Question. — Have you kept him regularly on the three-hour 
schedule? 

Answer. — Yes; but it's been very difficult. 

Weight. — Eleven pounds two ounces. No gain during the 
week. 

Temperature. — 98° F. 

Examination. — He presents just exactly the same appearance 
as last week. He's a little flabby and pale and apparently 
undernourished. 

Discussion. — As he hasn't gained this week, and in the ab- 
sence of any factor other than food, we feel sure of our diagnosis 
of inanition. I should add a bottle right now, but just to be 
absolutely sure that mother is secreting an insufficient supply of 
milk let's wait a few days longer. You remember that this 
child drank sugar water between meals. Possibly he was so 
spoiled, due to the sweet taste of the water, that for this reason 
he has refused the breast. 

Directions. — Let's try him just one week more, and then, if he 
doesn't gain, we certainly shall be justified in adding a bottle. 
There is a bare possibility, though, that by adhering rigidly to 
our routine the child will nurse vigorously enough to increase 
the supply of breast milk. Be sure to come back next week, 
mother. 

Question by Mother. — But doctor, what shall I do for the colic? 
Shall I have my breast milk examined? 

Answer. — All right, mother, give Dr. Meadows a specimen 
of your breast milk. 

Discussion. — Gentlemen, you have heard about qualitative 
changes in breast milk, but examination will make mother feel 
easier. Personally, I'm convinced that this colic is due to 
hunger, as the child hasn't gained the required amount. How- 
ever, to make sure, let's wait another week and see exactly what 
he's doing. 

To Mother. — I think we can aid the baby greatly if you'll 
just follow our instructions for this next week. See if you 



308 INFANT FEEDING (CHICAGO METHODS) 

can't put up with his crying for a few days and then we'll fix 
him. 

Question by Dr. Summerell. — Have you any babies of your 
own, doctor? 

Answer. — No; but I see by your smile that you think my 
ideas will change. 

Dr. Woodson. — Doctor, it's all very well in clinic to tell these 
mothers, " If baby is crying, let him alone," but we can't do that 
in practice. When we are called up at 3 a. m. and father says, 
wearily, "I never knew I could walk ten thousand miles in one 
evening," we've got to say something more to him than simply 
" weigh the baby." 

Answer. — Gentlemen, I accept the reproof. The reason I 
didn't lay much stress upon the colic is my earnest desire to 
teach you to put the welfare of the baby above the relief of any 
individual symptom. As regards the immediate relief of colic, 
an enema may save the day, or, rather, the night. The enema 
can be given in the form of salt solution, — a teaspoon of salt to a 
pint of water, — or, if this is not satisfactory, as a soapsuds enema. 
One drop of essence of peppermint in a teaspoonful of sweetened 
water, by causing internal warmth, will sometimes satisfactorily 
relieve pain ; or you may give a few drops of pepsin. Apply hot- 
water bags or hot flannels to the abdomen, and lastly, if the child 
must be relieved, give him a few drops of paregoric, and repeat in 
an hour or so. But, gentlemen, the point to be remembered is 
this: While advising this treatment, always ask yourselves, "Is 
this truly a case of intestinal colic?" Don't neglect to apply a 
little pressure to the ear; don't neglect to ask for a urinalysis 
as soon as possible. The colic, after all, may be simply an otitis 
media, a cystitis, or a meningitis. Second, ask yourselves, "Is 
this truly a case of colic from indigestion, or is it simply the pain 
of hunger?" For this latter reason I lay so much emphasis on 
the weight. Lastly, if it's a digestive affair, is it due to too much 
perfectly good food or is it due to an excess of one individual 
element of a food? We think that some colic in the breast fed 
is due possibly to excessive carbohydrate in the breast milk. 
So, gentlemen, although the relief of the immediate pain in a 
child is important and not difficult, don't forget that, after all, 



CLINICS 309 

the essential thing is to arrive at the underlying factor and make 
a proper diagnosis. 

Question by Dr. F. Raymond Taylor (High Point). — Doctor, 
as long as we are on the subject, would you mind telling us just 
what is three months' colic? 

Answer. — Three months' colic is a term applied by the laity 
to the colic which occurs in breast-fed babies who seem thriv- 
ing, however, in every way. It lasts usually from three to six 
months, the baby suffering apparently from considerable in- 
digestion, and showing green, watery, fermentative stools. 
The etiology is not definitely known. I don't know of much 
scientific work upon it, as the condition is not of grave signifi- 
cance; the children all outgrow it. Two factors may be con- 
cerned : First, some evidence points to the fact that it occurs in 
nervous children — that it is due not to the milk, but to the baby. 
These neuropathic children, for some reason or other, do not 
seem able to control fermentative processes in the intestine as 
do normal children. The second factor, although not proved, 
might lie in an excess of sugar in the mother's milk. Certainly 
the stools of these children point to fermentation. 

The practical treatment of the colic, in which you gentlemen 
have shown yourselves so interested, is along the lines just laid 
out. To strike at the cause, however, we attempt to overcome 
intestinal fermentation. This can be done by giving a little 
powdered casein or powdered curds of milk after each nursing, 
or, by what sometimes works wonders, namely, a little albumin 
milk with no sugar, after the breast. This food, with its high 
protein, low salt, and low carbohydrate, by tending to stimu- 
late putrefaction in the intestine, sometimes accomplishes sur- 
prising results. 

In this case I'm positive that the crying is from hunger. In 
private practice I should have added a bottle to the diet several 
days after first seeing the child, but, unfortunately, the clinics 
come only weekly, and I'm very anxious to show you the differ- 
ent reactions of the weight curve uninfluenced by treatment. 
In this case the curve has remained horizontal, so we'll make 
mother put up with the noise just one week more. 



310 INFANT FEEDING (CHICAGO METHODS) 



CLINIC III.— BABY 1 

Age. — Four months three weeks. 

Mother says the child has not improved in any way, is still 
fretful, peevish, irritable, and doesn't take the breast well at all. 
No additional symptoms or complications have been noted. 
Bowels are constipated. Mother says that she hasn't much 
milk, and the baby cries all the time. In addition, the child 
shows some aversion to the breast and is not nursing well. 

Weight. — Ten pounds fourteen ounces, showing a loss of four 
ounces during the week. 

Temperature.— 97 .8° F. 

Question. — Mother, do you notice that your supply of milk is 
much less than it used to be? 

Answer. — Yes, indeed, the baby doesn't get much from the 
breast any more. 

Directions. — To confirm our diagnosis of inanition, — this loss 
is by no means sharp enough to suggest any of the graver dis- 
turbances, — we'll add a bottle after each nursing. Let's figure 
that the baby will drink about two ounces, and so if he's four 
and one-half months old we'll be absolutely safe in ordering a 
mixture of — 

Milk 9 ounces 

Water 6 ounces 

Sugar 4 teaspoonfuls 

Seven bottles. 

To Mother. — Mother, have you ever fixed up any feedings 
before? 

Answer. — No. 

Well, then, let me tell you just exactly how to proceed: In 
one corner of the kitchen put up a shelf, or else set aside a corner 
of the kitchen table. Use this exclusively for baby's food uten- 
sils, and don't mix them with anything else in the kitchen. 
First, get as many bottles as there are feedings during the day, 
or even a few more. Next take some whole milk, shake it 
thoroughly so that the cream is well mixed, and in your case 
pour out nine ounces. Add six ounces of water and four tea- 
spoons of sugar. Boil thoroughly for a minute and pour at 



CLINICS 311 

once into seven bottles. This makes about two ounces in each. 
If you let the mixture stand in an open pitcher for any length of 
time, it will spoil. 

Get a few cents' worth of sterile cotton and cork the bottles, 
keeping the unused cotton in its original package. Then you 
are through for the day. Of course, you must keep the bottles 
cool, either in the ice-box or, if you haven't one, in the well or 
in the stream. 

Nurse the baby for ten to fifteen minutes and then give a 
bottle. Let him have this five or ten minutes. If he takes it 
and is satisfied, well and good; but if he doesn't finish it in ten 
minutes, take it away from him. By all means nurse him first 
and give the bottle afterward, because if you give the bottle 
first, he will wean himself more easily. This way will be more 
likely to keep up your milk supply. 

Put the nipple on the bottle only at feeding time. Those not 
in use can be kept in a covered jar of boiled water with a little 
boric acid or soda. 

As regards washing the bottles : you may do so either at once 
or the next morning. If the latter, because milk sticks to the 
inside, get a bottle brush, scrub them with yellow soap, and 
rinse them thoroughly afterward. If you wash them directly 
after using, keep the clean bottles in a jar with sterile water and 
a little soda. When you clean the nipples, be sure to invert 
them. It goes without saying that if the baby drops his bottle 
on the floor you must take out another nipple. 

When you give the baby his bottle, be sure to see that he 
really gets it. Don't leave him all alone to go to sleep, but do 
your best to hold it and give it to him with the same care that 
you would if you were nursing him. Hold the bottle so that he 
really gets milk, not air. 

Warm the bottle just before giving it to him by putting it in 
a little warm water, but if you take the baby out for the day, 
don't make the mistake of heating the bottle before you go. 
Wait until feeding time or else the milk will spoil. You can do 
a good deal toward keeping the bottle cool by wrapping it 
thoroughly in a newspaper before you go out. 

Let's see him again next week, and when you come back tell 
us how he is. We'll weigh him and see how he has responded. 



312 INFANT FEEDING (CHICAGO METHODS) 

Question. — Have you understood everything, mother? 

Mother. — If I am to give seven bottles with two ounces, 
should I add five or six ounces of water? 

Answer. — Six ounces, because about one will be lost during the 
boiling. 

Discussion. — It's always a good idea to add more water than 
you need on account of the boiling. You notice the simplicity 
of the formula? It required no calculation on my part what- 
soever. It consists simply of two-thirds milk and one-third 
water, with a little sugar. 

In cases such as this I prefer to add a bottle after each nursing, 
but when such order works hardship on a mother who is weak 
or who must work, we may give breast and bottle in alternate 
feedings. 

Whenever I order a bottle I start orange-juice. You may 
dilute it with water, or give half a teaspoon of the pure juice. 
In either case the baby may vomit the first dose or have a little 
colic. Don't pay any attention to these symptoms, but give it 
again the next day, and in a short time you'll find baby taking 
it nicely. 

CLINIC IV.— BABY 1 

Age. — Five months. 

Baby is very much better. He takes his bottle after each 
nursing and likes it ever so much. He vomits just a little bit, 
but sleeps through the night now. He is quiet for three hours 
and seems a different baby. 

Weight. — Eleven pounds eight ounces, a gain of ten ounces in 
a week. 

Temperature. — 98° F. 

Examination. — The child certainly looks better and happier 
and begins to have the contented look of the normal baby. 

Discussion. — With such a nice response of the weight we ig- 
nore absolutely the vomiting. The baby's general nutrition, 
which is the point in which we are interested, has certainly im- 
proved. 

Directions. — Mother, keep up this treatment and let's see him 
again in a week. 



CLINICS 313 



CLINIC V.— BABY 1 

Age. — Five months one week. 

Mother says the baby is doing nicely, but that he is a little 
hungry; that no sooner does he empty his bottle than he cries 
for the next one. 

Weight. — Eleven pounds fifteen ounces, showing a gain of 
seven ounces during the week. 

Temperature. — 98.6° F. 

Examination. — Child looks bright and happy. 

Discussion. — I don't think we can complain of that gain in 
weight, and I should advise the mother to let him absolutely 
alone. He is gaining really faster than he should. 

Mother says: "That is all right, doctor, but I have no breast 
milk. For the last week my breast milk has gone entirely, and 
to tell the truth, I have given him more of the bottle myself." 

Directions. — Well, that's different. We'll put him on regular 
bottle feedings for a baby of his age. He's over four months 
old, so we'll order — 

Milk 20 ounces 

Water 11 ounces 

Sugar 6 teaspoonfuls 

Five feedings and start a little cereal. 



CLINIC Vm.— BABY 1 

Age. — Six months. 

Mother says the baby did all right for a week, but for the last 
two has been hungry and not gaining. 

Weight. — Twelve pounds eight ounces, showing a gain of nine 
ounces in three weeks. 

Temperature.— 38.6° F. 

Examination shows him to be in good condition. 

Directions. — Mother, baby is now six months old; so you 
gradually may offer a greater variety of food. Very slowly add 
a little soup or vegetable or chicken broth. Give an occasional 
Graham cracker or a little zwieback, which is the same as hard, 
dry, doubly baked bread. If you can't get it, take some toast 
and bake it thoroughly until very hard and dry. Give the 



314 INFANT FEEDING (CHICAGO METHODS) 

zwieback or Graham cracker mashed up with a little broth, or 
soaked in the soup or the bottle, or baby may like to take it in 
his hand and chew it. In addition to these, start a variety of 
cereals, such as farina, corn-starch, Cream of Wheat, or arrow- 
root. 

We can begin with vegetables : you may use almost any that 
can be boiled to soft consistence, put through a sieve, and made 
into a puree. This includes mashed potatoes. Perhaps the 
best at first is spinach or carrots. Carrots are best given if 
cooked and then grated right into the soup. 

Of course, the baby must have fruit-juices, such as orange- 
juice, prune-juice, and also a little apple-sauce or baked apple. 
A six-months-old baby may have a strip of bacon. Bacon 
directly from the shop is a little salty; so it's a good idea to soak 
it first in water to rid it of this excess, and then broil it rather 
crisp. You may start, too, with beef -juice. 

Question by Mother. — How shall I cook the cereal? 

Answer. — If you are using farina, take a tablespoonful to a 
cup of water; boil this over the fire for half an hour. As the 
water boils away, of course, add fresh water. In the last few 
minutes add about half a cup of milk. You must stir this con- 
stantly; if you use a double boiler, you won't need to use so 
much care, but you must cook it for over four hours. Add a 
pinch of salt and enough sugar to sweeten slightly. In making 
corn-starch I would use perhaps a little less than a tablespoonful 
because the corn-starch thickens easily. 

Question by Mother. — We don't have farina down here; I 
never heard of it, but could we use hominy or a little mush in- 
stead? 

Answer. — Yes, those would do exactly as well. 

Question by Mother. — How about oatmeal? 

Answer. — Some children take oatmeal very well at six months, 
but to some it seems rather laxative. Of all cereals, oatmeal 
seems most likely to ferment and cause diarrhea in children of 
this age. 

Question by Mother. — How shall I prepare the beef -juice? 

Answer. — Cut the beef into tiny cubes, throw them into a hot 
pan to sear the outside, and then squeeze out the juice. You 
may give a teaspoonful or more a day. 



CLINICS 315 

Question by Br. Meadows. — Would you use fresh or canned 
vegetables? 

Answer. — If possible, I would certainly use the fresh. By 
the way, if you have any trouble in making puree, we have a 
little apparatus in the hospital at home which is of great value. 
It's a little grinding mill put up by the Enterprise Manufactur- 
ing Co., of Philadelphia, called the "Nixtamal Mill." It's in- 
expensive, costing only a few dollars, and certainly is very satis- 
factory. Dr. Abt introduced it into our hospital, trying it as a 
means for pulverizing casein and curds in the making of albu- 
min milk. 

Of course, in starting the baby out don't give him a banquet 
the very first day. You must use considerable discretion and 
care. I think I should start out perhaps like this: Tomorrow, 
after the 10 o'clock bottle, add a half teaspoonful of the farina 
or corn-starch. This being a new food, may be vomited; don't 
pay any attention to this vomiting, but repeat the next day. 
Gradually, day by day, increase the dose, so that by the end of 
two or three weeks he gets the whole quantity. A few days 
after giving the cereal start, in addition, one of the other foods, 
as a little broth or a teaspoonful of vegetable puree after the 
2 o'clock bottle. A few days later, having increased the quan- 
tity of broth to an ounce or more, try a few crumbs of zwieback 
broken into the broth. In two or three weeks, when you have 
learned which foods baby prefers, give him at 2 o'clock a little 
dinner of broth, zwieback, a little vegetable and beef -juice, or 
bacon. Then, of course, he won't take so much of his bottle; 
but remember, it's essential to start gradually and increase very 
slowly. As baby is getting small amounts of food the first few 
days, he won't gain much, and we must tell mother in advance, 
so that she won't be discouraged if there isn't a marked gain 
next week. 

Question by Dr. Brown. — Don't you think, doctor, this is a 
pretty full diet for so young a baby? 

Answer. — I suppose it seems that way; I doubt if you will 
find it prescribed in many texts. On the other hand, if you 
will only try it as I have outlined, I am sure you will agree with 
me that it is very successful. I have had many discussions and 
been forced to overcome many objections, particularly from the 



316 INFANT FEEDING (CHICAGO METHODS) 

nurses, but I believe you will find that such a diet will be adopted 
more and more. Certainly the brilliant results we get at home 
are sufficient evidence in its favor. From my own point of 
view I believe that our fear of overfeeding babies has carried us 
to the other extreme, and that many babies of this age really 
are underfed. Of course, I don't mean that you should cram 
food into a child and stuff him : simply give him what he wants 
and you will find that upon the four-hour schedule he adjusts 
his diet to his own needs and practically never overfeeds him- 
self. Of course, you must remember that as he takes more 
solid food he drinks less of his bottle; so don't force the bottle 
upon him. And remember that his daily diet shouldn't contain 
everything in this list, but just should be selected from it. 

Question by Mother. — Can I add an egg? 

Answer. — No, I should not advise this as yet. It is true that 
some children, as early as the eighth or ninth month, take a soft- 
boiled egg and tolerate it well, but it is wiser, with the majority 
of children, to wait until they are somewhat over a year. 



CLINIC VII.— BABY 1 

Age. — Six months one week. 

Mother says the diet is causing diarrhea. She has given a 
little spinach, and he likes it very much. He seems happy and 
sleeps well, but has a diarrhea, with four or five watery stools 
daily. 

Weight. — Twelve pounds ten ounces, a gain of two ounces in a 
week. 

Temperature. — 98.6° F. 

Examination. — Well, gentlemen, he looks well, doesn't he? 
Notice he seems happy, contented, smiling, and he kicks and 
stamps and waves his arms. He's interested in everything 
about him, so no matter what mother tells us about his bowels, 
the baby looks all right, and the gain in weight, though slight, 
proves this. Probably he hasn't eaten enough to cause a greater 
gain. 

Discussion.— In many cases diarrheas occurring upon addi- 
tion of solid food, though attributed to the diet, depend upon 
absolutely other factors. 



CLINICS 317 

Question. — Mother, have you been feeding the baby as we 
told you? 

Answer. — I started in very slowly and carefully, and he is 
getting just a little cereal, broth, and yesterday some spinach. 

Question. — How long have the bowels been loose? 

Answer. — Three days. 

Question. — Have you given any medicine? 

Answer. — Yes. I was afraid he wouldn't digest the cereal 
very well, and so I gave him three teaspoons of castor oil for the 
last three days. 

Discussion. — No more explanations are necessary, gentlemen. 
The castor oil explains the diarrhea. 

A nice illustration of diarrhea occurring upon change of diet 
is one I saw yesterday. The baby, one year old, was brought 
for feeding. He had been breast fed until three weeks before. 
We ordered a soft diet and a milk mixture of — 

Milk 20 ounces 

Water 11 ounces 

Five feedings. 

We told mother to wean him gradually. 

On his return mother reported a diarrhea, which she ascribed 
to the soft diet. Questioning revealed that in trying to wean the 
baby she had put salt on her nipples to make them distasteful. 
The baby liked this addition and took to it eagerly; so the in- 
genious mother added pepper. This combination proved too 
much, and the diarrhea resulted. 



CLINIC VIII.— BABY 1 

Age. — Six months two weeks. 

Mother says the baby is well in every respect — the bowels 
move two to four times a day. He likes his vegetables, and is 
content and happy. 

Weight. — Thirteen pounds one ounce, a gain of seven ounces 
in the week. 

Discussion. — You see, gentlemen, what one accomplishes by 
judicious use of a soft diet. Let's let him alone. 

Mother, you might bring him back in two or three weeks. 



318 INFANT FEEDING (CHICAGO METHODS) 

CLINIC I.— BABY 2 
Dr. J. D. Williams (Greensboro) 
Age. — Five weeks. 

History. — Negative. Mother has no breast milk and comes 
for feeding advise. 

Temperature.— 98.8° F. 
Weight. — Seven pounds three ounces. 
Examination. — Normal baby. 
Directions. — 

Milk 11 ounces 

Water 11 ounces 

Sugar 4 teaspoonf uls 

Seven feedings. 

Don't omit orange-juice. 
Let's see the baby next week. 

CLINIC II.— BABY 2 

Age. — Six weeks. 

Mother says the baby is not doing well ; that he cries, doesn't 
want to eat, has colic, and is awfully constipated. The food 
doesn't agree with him. He doesn't even empty his bottles, 
and his mouth is very sore and all white. 

Temperature. — 99.4° F. 

Weight. — Seven pounds four ounces, showing a gain of 
one ounce in the week. 

Examination. — Negative, except for white patches all over 
gums and mucous membrane of the cheeks. 

Discussion. — Gentlemen, you see the value of our scales. 
This week the child gained only one ounce — an insufficient gain, 
of course. Can this be due to an acute disturbance from over- 
feeding? No, because there is no acute loss in weight — simply 
failure to gain. There is no diarrhea; indeed, the baby is very 
constipated. It's more likely that the pain is that of hunger, 
and that the failure to gain is from insufficient food. 

Diagnosis.— We diagnose mild inanition, and ask, " Why isn't 
he drinking his full bottle? " Is it because he doesn't like it? 
Is it because he has bronchitis, or something interfering with his 



CLINICS 319 

drinking? Our examination has answered this question at a 
glance. 

Question. — Mother, you've been washing out the baby's 
mouth. What have you used? 

Answer. — The druggist recommended some silver nitrate to 
me. 

Discussion. — See how a little disturbance absolutely inde- 
pendent of food may arise, and lead you, if not careful, to diag- 
nose improper feeding! Here is an excellent illustration of 
thrush and the improper way of treating it. Thrush, you know, 
is an infection by a fungus. The fungus never attacks an in- 
tact mucous membrane, but only one that has been injured. 
The surest way of predisposing the child to infection is to wash 
the mouth with any strong solution or with sufficient mechanical 
violence to cause injury. Remember, the intact mucous mem- 
brane is immune. During my experience in the Finkelstein 
clinic we could tell at a glance from which maternity hospital 
our patients came. All those who had thrush came from an 
institution where it was routine to wash the babies' mouths. 
Those without thrush came from one where the mouths were 
let alone. There is no surer way of inviting thrush than to wash 
out the mouth roughly. Better let it go unwashed. 

Directions. — Mother, for the next few days let the baby's 
mouth absolutely alone. Once or twice a day saturate a little 
cotton with half peroxid and half water, and just touch the white 
spots on the gums and cheeks. Don't rub them or scrape them, 
but touch them as gently as if you were taking up a blot with a 
piece of blotting-paper. When his mouth is healed and it 
doesn't hurt to drink, I think he'll take his bottle better. For 
the next few days, as his mouth is so sore, feed him with a spoon 
or a medicine-dropper. 



CLINIC IE.— BABY 2 

Age. — Seven weeks. 

Mother says the baby is drinking the bottle with renewed 
vigor, but that he's hungry. 

Weight. — Seven pounds five ounces, showing a gain of one 
ounce in a week. 



320 INFANT FEEDING (CHICAGO METHODS) 

Temperature— 98.6° F. 

Examination shows the mouth in much better condition. 

Discussion. — As this gain is insufficient, and as the baby now 
is taking his entire food as offered, the failure to gain must be 
due to insufficient amount. 

Directions. — We'll order an increase to — 

Milk : 13 ounces 

Water 12 ounces 

Sugar 6 teaspoonfuls 

Seven bottles. 



CLINIC IV.— BABY 2 

Age. — Eight weeks. 

Mother says baby is doing nicely; that he drinks well and 
seems satisfied. Until yesterday he had been quite constipated, 
but yesterday his bowels moved three times and she noticed a 
lot of white, hard curds in the stool. The other day he had a 
little cold. 

Weight. — Seven pounds fourteen ounces, showing a gain of 
nine ounces in the past week. 

Temperature— 98.8° F. 

Examination. — Negative, other than coryza. 

Discussion. — Gentlemen, as he gained nine ounces in the past 
week, we're not going to worry about the bowel trouble. Un- 
doubtedly it resulted from the coryza, with secondary fermen- 
tation in the intestine, but you see for yourselves, from the 
happy appearance of the child and from the decided gain, his 
nutrition is in no way affected. 

Question. — Mother, are you boiling the milk? 

Answer. — No, doctor, I thought it would be better to give it 
raw. 

Directions. — Mother, if you will boil the milk the hard curds 
will disappear from the stool. Use a little liquid vaselin for the 
nose, and when the cold is better his bowels will correct them- 
selves. If they don't in a day or two, the doctor will order some 
chalk mixture. 



CLINICS - 321 

CLINIC I.— BABY 3 

Dr. C. S. Gilmer (Greensboro) 

Age. — Seven weeks. 

History. — Mother lost her milk and has never nursed any of 
her babies over a few weeks. She comes for advice. 

Temperature. — 98.6° F. Weight, seven pounds fifteen ounces. 
Examination shows a happy baby. Everything negative. 
Discussion. — He has been getting — 

Milk 14 ounces 

Water 14 ounces 

Sugar 6 teaspoonf uls 

Seven feedings. 

This seems a perfect formula. You notice it's half milk and half 
water, and approximately 3 percent carbohydrate. The total 
quantity is a little above the average for babies of this age, but 
if he's taking it well and not vomiting, I don't believe it needs to 
be changed. 

Directions. — Continue this formula. Don't forget to shake 
the milk thoroughly before making up the mixture, and don't 
forget the orange-juice. 

CLINIC II.— BABY 3 

Age. — Eight weeks. The baby is fine, happy, and contented 
in every way. 

Weight. — Eight pounds four ounces, showing a gain of five 
ounces. 

Temperature.— 98.8° F. 

Examin ation. — Negative . 

Directions. — Baby is doing well, but you had better bring him 
next week. 

Discussion. — Gentlemen, I like to have the babies return as 
often as possible. It's the best means to keep a check on them. 
Those who don't return, puzzle us: may be the diet didn't 
agree with them. On the other hand, may be it agreed with 
them so well that the mother thinks her troubles are over — a 
dangerous conclusion, however. As I have tried to emphasize, 
any baby upon the bottle is to be regarded as sick, and I urge 
21 



322 INFANT FEEDING (CHICAGO METHODS) 

you to impress this upon your patients and have them return as 
frequently as possible. 

CLINIC III.— BABY 3 

Age. — Nine weeks. 

Mother says the baby seems to be doing pretty well but is 
hungry. He had a croupy cough for the last two or three days. 
His bowels are constipated, with hard stools. 

Weight. — Eight pounds two ounces. Loss of two ounces in 
the week. 

Temperature.— 99.2° F. 

Examination. — Very slight bronchitis. 

Question. — Mother, does the baby vomit when he coughs? 

Answer. — No. 

Question.— -Is his cough worse at night or in the daytime? 

Answer. — It's worse in the daytime. 

Question. — Does he whoop at all? 

Answer. — No. 

Discussion. — Gentlemen, in all cases of coughing in children, 
don't overlook pertussis. In this case we're glad to hear that 
the stool is constipated, although the mother looks shocked. 
Children, especially the young ones, when they develop coughs 
or colds, show severe diarrheas and nutritional disturbances. 
The fact that this child hasn't reacted shows, first, that his 
intestinal tract is unaffected, and, second, that we needn't 
fear increasing his diet. Mother says he's hungry and would 
like more. If, however, he were having a diarrhea associated 
with this cough, we certainly shouldn't order an increase. The 
weight shows a loss of two ounces this week, yet the mother says 
he empties all his bottles. If he were having a diarrhea at this 
time, we might diagnose a mild dyspepsia. The fact that he's 
constipated ; that he empties all the bottles and still is hungry, 
makes us believe that his failure to gain is not due to any com- 
plication but simply to insufficient food. 

Directions. — We'll order — 

Milk 16 ounces 

Water 16 ounces 

Sugar 7 teaspoonf uls 

Seven bottles. 



clinics 323 

I warn you this is rather daring for children suffering with in- 
fections, but the fact that he looks and acts perfectly well — 
notice his rosy color and his pleasant smile — and that he is 
hungry, warrants, I believe, this increase. 

CLINIC IV.— BABY 3 

Age. — Ten weeks. 

Mother says the baby is in fine condition. His bowels move 
once a day, sometimes twice. 

Weight. — Eight pounds nine ounces, showing a gain of seven 
ounces in the last week. 

Temperature.— 38.6° F. 

Examination. — Negative. 

Directions. — As long as he is gaining we'll make no change. 

CLINIC V.— BABY 3 

Age. — Eleven weeks. 

Mother says the baby is in good condition, but thinks he is 
a little hungry. 

Weight. — Nine pounds one ounce, showing a gain of eight 
ounces during the week. 

Temperature. — 98.6° F. 

Examination. — Negative. 

Directions. — As the gain is surely normal, better make no 
change in the feeding, except from seven to five feedings, with- 
out altering the total quantity. 

CLINIC VI.— BABY 3 

Age. — Three months. 

Mother says the baby is hungry. 

Weight. — Nine pounds four ounces, showing gain of only three 
ounces in the week. 

Temperature.— 38.6° F. 

Examination. — Negative. 

Directions. — As he gained only three ounces this week, I think 
we are justified in ordering a slight increase in diet. He's now 
three months old. We either may increase the amount and 



324 INFANT FEEDING (CHICAGO METHODS) 

thus the concentration of the milk exclusively, or we may in- 
crease the total quantity, leaving the concentration unchanged. 
As I like to limit the total to a quart, I'd suggest — 

Milk 18 ounces 

Water .13 ounces 

Sugar 8 teaspoonfuls 

Five bottles. 



CLINIC VII.— BABY 3 

Age. — Three months one week. 

Mother says the child has been crying all the time, that his 
bowels are "running off" about seven or eight times, with lots 
of mucus and curds. She thinks the increase in the diet was 
too much. He has severe colic and is not gaining. He doesn't 
want the bottle and vomits sometimes. 

Weight. — Nine pounds four ounces. No gain this week. 

Temperature. — 101° F. 

Examination reveals nothing except this — notice how pressure 
on the tragus of the right ear makes him wince and cry. 

Discussion. — Gentlemen, in 90 percent of cases by this method 
you can diagnose complications in the auditory canal or the 
middle ear. Don't attempt to penetrate the cranial cavity, 
but just exert the mildest sort of pressure. A perfectly normal 
baby will pay no attention. A baby who is crying, will con- 
tinue, but will do nothing else. This child, however, not only 
cries, but winces and jerks his head away sharply. We have, 
then, either a furuncle in the auditory canal or an otitis media. 

Examination. — The otoscope reveals an inflamed ear-drum. 

Directions. — This baby should see the ear doctor. And now 
we have a dyspepsia and colic, not directly from food, but 
secondary to otitis media. Shall we change the diet in this 
case? Not at all, because although there has been a fermenta- 
tion in the intestinal tract, this fermentation has not been 
severe enough to interfere markedly with the child's nutrition. 
He is not losing any weight; so, mother, for the present let the 
baby alone as regards his diet — let him take what he wishes, 
feed him regularly, and see an ear doctor. He won't want 
much for a few days because he has fever; so don't try to force 
him. Use a few drops of a 5 to 10 percent solution of carbolic 



clinics 325 

acid in glycerin in that ear every three to four hours for a day or 
two until you see the ear doctor. 

Use a few drops of pepsin in a teaspoonful of water for the 
colic. 

CLINIC VHI.— BABY 3 

Age. — Three and one-half months. 

Mother says the baby seems well. The ear trouble and 
dyspepsia have disappeared, and he is satisfied and happy. 

Weight. — Nine pounds nine ounces, showing a gain of five 
ounces in the week. 

Temperature.— -98.6° F. 

Examination. — Negative. 

Directions. — No change. 

CLINIC I.— BABY 4 
Dr. D. A. Stanton (High Point) 

Age. — Eighteen months. 

History. — Negative, other than that the child has- been suffer- 
ing for six months from repeated attacks of otitis media. 

Temperature.— 38.6° F. 

Weight. — Twenty-three pounds. 

Physical Examination. — This shows a pasty, pallid, rachitic 
child, who looks anemic and water-logged, although there is no 
edema. There are no adenoids nor large tonsils. Right ear 
discharging. 

Discussion. — Gentlemen, I am no ear specialist. However, 
the child's general nutrition in a way might account for this 
condition. Of course, in such a child we must rule out tubercu- 
losis, syphilis, hookworm, nephritis, blood diseases, etc. Let's 
see if the feeding is a factor. 

Question. — Mother, how have you been feeding the baby? 

Answer. — I give him mostly milk. 

Question. — Don't you give him anything else? 

Answer. — Well, sometimes I give him a little hominy or mush 
or toast. 

Question. — Anything else? No vegetables, eggs; anything 
like that? 



326 INFANT FEEDING (CHICAGO METHODS) 

Answer. — No, that is all he gets; sometimes a few Graham 
crackers. 

Discussion. — I think that explains part of the difficulty. The 
diet of milk and carbohydrate, you remember, is the one caus- 
ing water-logging of the body, and you remember we spoke of 
the fact that children such as these seem to have a lessened im- 
munity to disease. I am glad of the opportunity to demon- 
strate such a case to you, because here we have a disturbance of 
nutrition not following a parenteral infection, but really pre- 
disposing to one. 

Directions. — Let's refer the child to the ear doctor, but in the 
meantime get him on a well-regulated diet, and try to increase 
his general resistance and immunity. Of course, we'll order 
cod-liver oil with phosphorus. 

CLINIC I.— BABY 5 
Dr. A. C. Whitaker (Julian) 

Age. — Six months two weeks. 

Weight. — Thirteen pounds one ounce. 

Temperature.— 100.6° F. 

Examination shows coryza, slight bronchitis, and a mud- 
colored skin. 

History. — Negative up to the present. Baby has gotten the 
breast and a mixture of — 

Milk 6 ounces 

Water 7 ounces 

Sugar 3 teaspoonfuls 

Six bottles. 

For two weeks he has had a soft diet. Mother thinks the 
feedings are not agreeing with the baby, who for the last few 
days has vomited, had diarrhea, with six or seven stools a day, 
and refused food. The baby has lost seven ounces during the 
week. 

Discussion. — This sounds like a true dyspepsia. Of course, 
the loss of weight could arise from insufficient food, but we ques- 
tion whether a child who has been gaining normally up to the 
present would, all of a sudden, drop back seven ounces in one 
week. Vomiting, except in extreme cases, is rarely associated 



clinics 327 

with underfeeding. Diarrhea may be present in inanition, as 
well as in other conditions, but from the general symptomatol- 
ogy, the loss of weight, the vomiting, the diarrhea, and the 
anorexia, we diagnose dyspepsia. The cause of the dyspepsia 
surely can't be the food upon which the child up to the present 
has been thriving, and we must seek it in other factors. 

Question. — When did you start the soft diet? 

Answer. — About a week ago. I gave a little cereal. 

Question. — How long has he been coughing? 

Answer. — He got sick about five days ago. 

Question. — When did the diarrhea start? 

Answer. — It started three or four days ago. 

Question. — Are his cough and cold better or worse? 

Answer. — The cough, I think, is better. 

Discussion. — Here we have a parenteral infection occurring 
with the change in diet. The mother blames the diet. We 
believe, however, that the cough and cold predisposed the child 
to a mild fermentation in the intestinal tract, and that the re- 
action was just severe enough to make us careful. In a baby of 
this age on a soft diet secondary disturbances are not severe. 
In a study some time ago* we found that the best dietetic treat- 
ment for these secondary diarrheas in children on a soft diet 
is to let them alone and not to vary the diet too dogmatically. 

Directions. — In this case the doctor will treat the cough and 
cold as he sees fit, and we'll leave the diet unchanged. Let the 
baby eat what he wishes. He won't eat very much for a few 
days, and by no means force him. To please the mother, let's 
order a little chalk mixture every three or four hours. 

CLINIC II.— BABY 5 

Age. — Six months three weeks. 

Mother says the baby still has coryza, a bad cough, and won't 
eat. The diarrhea is better, but yesterday he had four rather 
loose movements. 

Weight. — Thirteen pounds one ounce. No gain. 

Temperature.— 100.2° F. 

Examination. — Coryza and bronchitis. 

* "Studies on Parenteral Infections," Archives of Pediatrics, 1916, 671. 



328 INFANT FEEDING (CHICAGO METHODS) 

Discussion. — Gentlemen, the child has not gained during 
this past week. Probably he hasn't eaten as much as usual. 
The persistency of the bronchitis, with the associated fermenta- 
tion in the intestine, however, makes us hesitate about urging 
any forced feedings, particularly as mother says baby is not 
hungry. Let's wait another week until he gets over this cold. 



CLINIC in.— BABY 5 

Baby much better. Cough improved. Appetite returned. 
Weight. — Thirteen pounds ten ounces. Gain of nine ounces. 
Examination. — Negative. 

CLINIC L— BABY 6 
Dr. A. F. Fortune (Greensboro) 

Age. — Seven months. 

History. — Family history negative. The child was breast 
fed up to one month, then received malted milk for five months, 
but didn't do well; was hungry and had diarrhea all the time. 
Came to the doctor yesterday for advice. He's better now. 

Temperature.— -97.8° F. 

Weight. — Eleven pounds eight ounces. 

Examination shows baby only fairly nourished, with inelastic, 
mud-colored, thin skin which wrinkles easily, and flaccid muscu- 
lature. 

Discussion. — As the doctor has ruled out tuberculosis and is 
positive there is no trace of lues in the family, and as an exami- 
nation has ruled out anything of a constitutional nature, the 
findings, with this history of improper feeding, establish the 
diagnosis of mild decomposition of the alimentary type. 

Directions. — Just to contrast different methods of treatment, 
let's order a simple milk mixture and omit temporarily the soft 
diet. Mother give the baby — 

Milk 20 ounces 

Water 11 ounces 

Sugar 3 teaspoonfuls 

Boil this, divide it into five bottles of six ounces each, feed the 



clinics 329 

baby regularly once every four hours, and be sure to return 
next week. 

Discussion. — Gentlemen, personally for all children over six 
months of age I prefer a soft diet, but I'll order this milk mixture 
so that you may compare the result here with those of Baby 1. 

CLINIC V.— BABY 6 

Age. — Eight months. 

Mother says she didn't bring the baby back before because he 
gained so well for a few weeks she thought it wasn't necessary. 
For the last few days his bowels moved five or six times a day, 
he has vomited, and looks very puny again. No blood in the 
stools. 

Weight. — Ten pounds, showing a loss of one and one-half 
pounds in four weeks. 

Temperature.— 97 .2° F. 

Examination. — Negative as to causes other than feeding. 

Discussion. — The reason for this loss in weight easily is ex- 
plained. You know the great importance of carbohydrate. 
We withdrew sugar for just a few days, intending to supplement 
it with cereals, zwieback, and other non-fermentable carbo- 
hydrates. However, mother didn't bring baby back, and now 
for four weeks, due to lack of carbohydrate, and of course to 
other food elements, too, he has been developing a severe de- 
composition. 

The onset of the diarrhea a few days ago shows the beginning 
intolerance to food, and he now is in worse condition than when 
we first saw him. 

Directions. — We'll put him then on regulation treatment for 
decomposition. We'll reduce the concentration of the milk to 
about half — 

Milk 15 ounces 

Water 15 ounces 

Five bottles. 

We'll add non-fermentable carbohydrate to the mixture, 
approximately four teaspoonfuls of dextri-maltose, and to 
sweeten a little, I think it safe to add one or two teaspoonfuls of 
sugar. We'll give four ounces every three hours, and very care- 



330 INFANT FEEDING (CHICAGO METHODS) 

fully start zwieback and cereal once or twice a day. We may 
also offer carbohydrate in the form of a little mashed potato. 
Return in a week. 

Question by Dr. Woodson. — Did I understand you to say 
mashed potatoes for a baby of seven months in this condition? 

Answer. — Yes, if very thoroughly cooked and mashed and 
given in small doses this is a convenient way of giving non- 
fermentable carbohydrate. 

Discussion. — This was the child in whom we treated the 
condition of decomposition by an ordinary milk mixture instead 
of a soft diet. If the mother had returned, as she should have, 
the result would certainly not have been so unsatisfactory. 
Don't think that one will accomplish such poor results by the 
exclusive use of mik mixtures, but at any rate, on a soft diet, 
such an unfortunate occurrence could not have happened, for 
the child's demand for carbohydrate would have been covered 
by the cereals, potatoes, zwieback, and Graham crackers. 



CLINIC VI.— BABY 6 

Age. — Eight months one week. 

Mother says the child is much improved; he is eating zwie- 
back and cereal, and she is keeping the milk formula as directed. 
Bowels move two or three times daily and are almost normal. 

Weight. — Eleven pounds four ounces, representing a gain of 
one pound four ounces in a week. 

Temperature. — 98.4° F. 

Examination. — Child better and brighter. 

Directions. — No change in feeding is necessary. 



CLINIC VHL— BABY 6 

Age. — Eight months three weeks. 
Mother says the baby is doing nicely. 

Weight. — Twelve pounds, showing a gain of twelve ounces in 
two weeks. 

Temperature. — 98.6° F. 
Examination. — Doing nicely. 
Directions. — No change. 



CLINICS 331 

CLINIC I.— BABY 7 

Dr. Thomas Anderson (Statesville) 

Age. — Eight and one-half months. 

History tells us he is a premature, weighing three pounds at 
birth. After a few months of breast feeding mother lost her 
milk and gave — 

Milk 10 ounces 

Water 12 ounces 

Sugar 6 teaspoonf uls 

Seven bottles. 

He is hungry and suffers frequently from diarrhea. 

Temperature.— 97 .6° F. 

Weight. — Six pounds twelve ounces. 

Examination. — Having ruled out tuberculosis and syphilis, 
examination shows nothing more than an extremely rachitic, 
anemic, undernourished child in a state of decomposition. 

Directions. — You see the importance of a careful history. 
The fact that he is decidedly premature makes us very careful 
indeed, particularly as he is also in a state of decomposition. 
Let us wait a week and see what he is doing, except let's use 
dextri-maltose instead of sugar. 

CLINIC H.— BABY 7 

Age. — Eight months three weeks. 

Mother says the baby shows no change — that he still frets 
considerably. Bowels move three times a day. 

Weight. — Six pounds twelve ounces, showing no gain. 

Temperature.— 97.6° F. 

Examination. — No change. 

Directions. — Increase very carefully to — 

Milk 14 ounces 

Water 12 ounces 

Dextri-maltose 6 teaspoonfuls 

Seven bottles. 

Discussion. — In feeding prematures there are a few points to 
be considered: First, remember that in every case you should 
suspect lues — not that you will find it, but you always must 
consider it. 



332 INFANT FEEDING (CHICAGO METHODS) 

Next, if you are working with calories, prematures need more 
than do normal babies. Dr. Julius H. Hess, of our city, made a 
nice study recently, showing this higher requirement. This is 
easily understood, for the premature must gain not only as does 
a normal baby, but must make up back losses. 

An interesting point in feeding is brought out by Langstein. 
Up to this time the mortality of his prematures was very high. 
In many instances, when put to the breast, due to their great 
weakness, they tired before getting sufficient food, and from the 
resulting inanition, developed decomposition and death. Lang- 
stein found that, by forcing feedings either with a medicine- 
dropper or a stomach-tube, by getting more food into them, 
the mortality was greatly reduced. Gentlemen, if your pre- 
mature on the breast isn't gaining, don't waste time. Put him 
to the breast more frequently. If he still doesn't gain, force 
more food into him, either with a medicine-dropper or, if that 
fails, with a stomach-tube. In this baby we won't waste any 
time, but as his curve shows no gain, we increase at once. 

A valuable point is the following : Often the amount of breast 
milk necessary, overloads the stomach, causes vomiting, and 
defeats our purpose. This we readily may obviate by offering 
small quantities of buttermilk mixture— a mixture of boiled 
buttermilk with 5 percent dextri-maltose. This is food of high 
concentration, and is indicated particularly in prematures, who 
seem to need especially protein and salts. However, remember 
that this combination is one of concentrated whey with carbo- 
hydrate, and is likely to induce intestinal fermentation and 
nutritional disturbances; so under no circumstances offer more 
than one-third or one-half of the total amount of breast milk 
given. 

Clinical observation has taught that prematures and many 
twins develop, almost invariably, during the third or fourth 
month, severe anemias and bad rickets. It was Czerny who 
first offered an explanation. Just consider for a moment the 
composition of breast milk. In one quart there is -gV grain of 
iron and little over 7 grains of calcium. There is insufficient 
iron, barely enough calcium, to cover the needs of the child. 
Czerny suggested that during the last three months of intra- 
uterine life storage-warehouses of iron develop in the body. 



clinics 333 

The main one seems to be in the liver. During the first months 
of life, while baby is on the breast, he doesn't live on the iron of 
breast milk but upon that in the body. In a like manner, Czerny 
suggested calcium warehouses, although the latter are not quite 
so well established as the former. Now you see, gentlemen, why 
prematures develop anemia and rickets. They have come into 
the world before these deposits have been developed, and the 
supply of iron and calcium in breast milk is insufficient for their 
needs. In a like way, twins suffer because they have to share 
their supply with each other. 

It is a good idea, as a prophylactic, in all cases of twins and 
prematures, to add, after the first few months, a little calcium, 
some cod-liver oil, and often some iron. If you practise these 
methods of prophylaxis, you will be gratified with your success. 
Severe anemias rarely develop, and rickets appears only in its 
milder forms. 

The same conditions exactly develop in those children fed too 
long on the breast. Don't think for a minute that breast milk 
is the ideal food for a baby over six to nine months of age. There 
is nothing wrong with breast milk, but it doesn't supply suffi- 
ciently, the ingredients necessary. Of course, some children cover 
their demands by taking a larger quantity of milk from the 
breast, particularly if the mother has an abundant supply, but 
you'll find that most normal children, if kept exclusively on the 
breast after nine months of age, will develop anemias and rickets, 
just as do prematures and twins. 

From these studies of physiology, you will understand why I 
have always insisted upon a mixed diet for every child of six 
months of age. The purpose is to provide for these known defi- 
ciencies, and also for some of those, perhaps, whose existence, 
though now unknown, may be revealed in future observation 
and experiment. 

In regard to calcium, how we give it is unimportant, provided 
we give it in the form the baby likes. I should suggest a mixture 
of 

Calcium lactate 13^ drams 

Syrup of orange, to make 4 ounces 

Two teaspoonfuls three times a day. 

This gives about six grains of calcium three times daily. 



334 INFANT FEEDING (CHICAGO METHODS) 

The addition of cod-liver oil can be as follows : 

01. morrhuse 5 viij 

01. phosph 5j 

Sig. — Teaspoonful thrice daily after meals. 

As each teaspoonful contains one drop of oil of phosphorus, 
and as one drop of oil of phosphorus contains tw grain of 
phosphorus, a teaspoonful of this mixture contains tto" grain of 
phosphorus. You also may use mixtures of cod-liver oil and malt. 

These mixtures aren't delicious, but if you persist, children 
take them well. As they sometimes impair the appetite, it is a 
good idea to give them after the feeding. On the other hand, if 
baby vomits, give before the feeding. Then, if the baby vomits, 
it makes no difference. Don't pay any attention to the vomit- 
ing, but keep up the treatment, and the majority of children 
learn to take it readily. In some cases it may be wise to start 
with 10 to 15 drops and slowly increase to a teaspoonful. 



CLINIC HI.— BABY 7 

Age. — Nine months. 
Mother says child is still hungry. 

Weight. — Seven pounds, showing a gain of four ounces dur- 
ing the week. 

Temperature. — 98° F. 

Examination. — No change. Still peevish. 

Directions. — 

Milk 18 ounces 

Water 10 ounces 

Dextri-maltose 8 teaspoonfuls 

Seven bottles. 

Continue calcium and cod-liver oil. 

CLINIC VI.— BABY 7 

Age. — Nine months three weeks. 
Mother says baby is much better. 

Weight. — Eight pounds four ounces, showing a gain of one 
pound four ounces in three weeks. 
Temperature.— 98.8° F. 
Examination. — Child better. 



clinics 335 

CLINIC VH.— BABY 7 

Weight. — Eight pounds twelve ounces, showing a gain of 8 
ounces during the week. 
Better. 

CLINIC VHL— BABY 7 

Weight. — Nine pounds, showing a gain of 4 ounces during the 
week. 

Directions. — Give a little cereal and continue calcium and 
cod-liver oil. Slowly start a soft diet. 

Examination. — A fine baby. No signs of rickets other than 
a slight rosary. 

CLINIC I.— BABY 8 
Dr. S. F. Pfohl (Winston-Salem) 

Age. — Four and one-half months. 

History. — Family and past history are negative, except that 
during the first two days of life the child had fourteen hemor- 
rhages from the bowels. These stopped upon injections of 
horse-serum. Since then he has been on the breast, but is 
gaining slowly and is very pale. Mother now has no milk and 
is giving — 

Milk 10 ounces 

Water 9 ounces 

Sugar 5 teaspoonfuls 

Six bottles. 

He is not gaining on this and is very constipated. 

Temperature. — 97.6° F. 

Weight. — Seven pounds three ounces. 

Examination. — Rachitic baby of the decomposition type, with 
extreme pallor. 

Discussion. — Gentlemen, here is an example illustrating in 
another way the points of the previous case. This child suf- 
fered at birth a great loss of iron from his system, and the feed- 
ings since are insufficient to make up this great loss. 

Directions. — We'll increase his food slightly: 

Milk 14 ounces 

Water 8 ounces 

Sugar 6 teaspoonfuls 

Six bottles. 



336 INFANT FEEDING (CHICAGO METHODS) 

We also will offer iron, as we would to prematures and twins; 
here, however, not as a prophylactic, but as actual treatment. 
The most convenient form is the saccharated carbonate. The 
ordinary dose is three to four grains, but for practical purposes 
it is sufficient to tell the mother to take as much as she can put 
on the end of an ordinary knife. Give this to the baby in a 
teaspoonful of water about three times a day. Children take 
it well. 

CLINIC H.— BABY 8 

Age. — Four months three weeks. 

Mother says the baby is much better, but she is dissatisfied 
with the stools, which are green, watery, and contain curds. 
Three movements a day. The baby himself is happier and 
more contented. 

Weight. — Seven pounds ten ounces, representing a gain of 
seven ounces in a week. 

Temperature. — 98° F. 

Examination. — Color hasn't changed much. 

Directions. — As we are more interested in the baby than in the 
stools, and as he has gained more than we anticipated, we'll 
let him alone. Forget about the stools, and feed him just as 
you are doing. Return in a week. Continue the iron. 

CLINIC in.— BABY 8 

Age. — Five months. 

Mother says baby is better and brighter in every way. Stools 
are normal. 

Weight. — Seven pounds fourteen ounces. Gain of four ounces 
in a week. 

Temperature.— -98.2° F. 

Examination. — No change except a bit of color in baby's 
cheeks. 

CLINIC IV.— BABY 8 

Baby improving nicely. Is now hungry again and consti- 
pated. 

Weight. — Eight pounds one ounce. Gain, three ounces in the 
week. This is not sufficient and is an indication for more food. 

Temperature. — 98° F. 



clinics 337 

Examination. — Child looks fresher. More color to cheeks. 
Directions. — Continue iron. Increase diet to — 

Milk 16 ounces 

Water 9 ounces 

Sugar 7 teaspoonf uls 

Six bottles. 

CLINIC I.— BABY 9 
Dr. R. E. L. Flippen (Pilot Mountain) 

Age. — Four months. 

History^ — Family and past history negative. As regards 
feeding: -He received condensed milk during the first two and 
one-half months. The mother couldn't nurse him, and at that 
time he suffered severe dysentery, with sixteen stools a day. 
These showed blood infrequently. For the most part they 
were thin and watery, with mucus — probably not of the infec- 
tious type. 

From then until the present the child got Mellin's Food and 
barley water. He doesn't seem doing well, cries incessantly, 
and apparently the food is not agreeing with him. He is suffer- 
ing from no cough, fever, or other disturbance. The only 
symptoms seem to be indigestion, occasional vomiting, and 
frequent attacks of diarrhea. At present stools are about four 
to six a day — green, watery, with mucus and curds. 

Temperature. — 98° F. 

Weight.— Ten pounds nine ounces. 

Examination. — Almost the first glance tells us that he belongs 
to the disturbances of nutrition. You notice the flabby, in- 
elastic skin, its peculiar muddy color particularly about the eyes 
and cheeks, and the bluish rings around the eyes. The sore 
buttocks suggest acid stools. Notice how he. puts his fist in his 
mouth. He doesn't cry, but he doesn't look happy. Notice 
the tenseness and rigidity of the muscles. This occurs often in 
children on one-sided carbohydrate diets. Of course, we must 
not jump to such a conclusion without ruling out diseases, as 
meningitis or birth paralyses, but examination, excepting for a 
few cervical glands of pea size, is absolutely negative. 

Diagnosis. — We have here a mild decomposition. This child, 
however, is also in a condition of dyspepsia, and I am glad he 
22 



338 INFANT FEEDING (CHICAGO METHODS) 

came today, because he illustrates nicely the subject of the 
lecture. 

Treatment. — Mother, in order to give his stomach and in- 
testines a rest, for the remainder of the day give him absolutely 
nothing but a little weak tea. You may sweeten it with a 
pinch of sugar, but just enough to sweeten it slightly. 

Question by Mother.— How shall I give it? 

Answer. — At his regular feeding hours, 6, 10, 2, 6, and 10 
o'clock. Give him as much as he wants at these times, and 
nothing whatsoever between meals. 

Question by Mother. — What kind of tea shall I give? 

Answer. — Any tea at all that you use at home, green or black, 
provided you make it weak. Tomorrow start with a mixture 
of one-third milk: 

Milk 10 ounces 

Water 20 ounces 

Sugar 3 teaspoonf uls 

Five feedings. 

Keep him on this for two days, and then push him up gradu- 
ally by the end of the week to — 

Milk 15 ounces 

Water 16 ounces 

Sugar 5 teaspoonfuls 

Five feedings. 

The doctor will see you during the week. 

To Doctor. — You see, we started the baby on one-third milk, 
and ordered the mother to increase it in a few days. I think 
it would be a good idea to run in and judge how the baby is 
doing before the mother makes this increase. Let your index, 
to the best of your ability, be the weight curve, and if the baby 
ceases losing weight and seems better, make the increase. On 
the other hand, if he should lose rapidly and the diarrhea con- 
tinue, better wait for a day or two. If you have no access to 
scales, perhaps it would be wiser to go by the number of stools 
in this case, and not increase unless the stools have decreased 
to approximately three or four a day. In all our treatment we 
are influenced far more by the number of the stools than by 
the appearance of the individual stool. 



clinics 339 



CLINIC H.— BABY 9 

Age. — Four months one week. 

Mother says the baby is better and happier in every way. 
He is very, very hungry and not satisfied with the bottle — he 
wants more — he can't wait four hours; indeed, she gives him a 
little in between. The stools have diminished to three daily. 

Weight. — Eleven pounds one ounce, showing a gain of eight 
ounces. 

Temperature. — 98° F. 

Examination. — Child looks fresher. 

Discussion. — Gentlemen, we are far happier with the gain in 
weight than we are with the diminished stools, although, of 
course, both are very gratifying to us. We now have the child 
in such condition that his general nutrition is improving. 

Directions. — I think, in such a condition, we can pay heed to 
the appeal of the mother and the baby and order an increase, 
as his present diet is, of course, insufficient. We '11 do this very 
carefully; but as the baby is gaining and happier in every way, 
I think we're justified. Let's increase to — 

Milk 18 ounces 

Water 13 ounces 

Sugar 6 teaspoonfuls 

Five bottles. 

I risk this, gentlemen, because the baby is over four months 
of age, and the older the child, of course, the less susceptible, 
but you notice we keep the concentration of milk still not much 
over one-half. 

CLINIC HI.— BABY 9 

Age. — Four months two weeks. 

Mother says the baby is much improved. The stools vary 
from three to four a day. He is hungry. 

Weight. — Eleven pounds four ounces, showing a gain of three 
ounces in one week. 

Temperature.— 98.2° F. 

Examination. — As before. 

Directions. — As he cries considerably; as the scales show in- 



340 INFANT FEEDING (CHICAGO METHODS) 

sufficient gain and the intestinal tract is in better condition, 
we increase to — 

Milk 20 ounces 

Water 11 ounces 

Sugar 6 teaspoonf uls 

Dextri-maltose 3 teaspoonfuls 

Five bottles. 

We add dextri-maltose, as it is not so sweet as cane-sugar and 
because it is less fermentable. 



CLINIC V.— BABY 9 

Age. — Five months. 

Mother says the baby is doing nicely, but for the last week he 
has been crying considerably. He doesn't vomit; has no colic; 
but just cries all the time. He has no cough, fever, diarrhea. 
He stops crying if she picks him up. 

Weight. — Twelve pounds one ounce, showing a gain of thir- 
teen ounces in the last two weeks. 

Temperature.— 98.8° F. 

Examination. — As regards temperature, foci of infection, 
otitis, pharyngitis, and urinalysis, negative. 

Discussion. — Gentlemen, we have here a baby who seems to 
cry all the time. Organically there is nothing wrong. Can it 
be the cry of hunger? No, for the child has gained thirteen 
ounces in two weeks. Can it be the cry of indigestion or over- 
feeding? No, for there has been no vomiting and the stools 
have been normal. The crying is not related to meals. We 
are tempted to believe the following : He is an only child. Ex- 
perience has taught that the mother of an only child usually 
is an exceedingly nervous individual. She fusses continually, 
carries him more than he should be carried, and often excites 
him. Is that true, mother? 

Mrs. Jones (nurse) states : I guess we'll have to admit that — 
the mother is really very anxious, and certainly the baby has 
stopped crying whenever she picks him up. 

Discussion. — Gentlemen, listen to that crying. It is not that 
of pain; it is characteristically that of temper. See the value 
of the weight curve! It is a greater guide to us even than baby's 



CLINICS 341 

disposition, though of course the latter is of value also. If we 
were guided in our feeding mainly by the child's temperament, 
we should have changed the diet in this case. Mother, pick 
up the baby and show us how to cure him. 

Treatment. — Mother instructed not to worry about the baby's 
crying; told that the cry is one of temper, and urged to let him 
cry to his heart's content for a few days. 

CLINIC VII.— BABY 9 

Age. — Five months two weeks. 

Mother says the baby is better. He cries much less, but she 
finds it difficult to restrain herself from picking him up. 

Weight. — Twelve pounds fifteen ounces, showing a gain of 
fourteen ounces in two weeks. 

Temperature.— -98.8° F. 

Examination. — Negative. 

Directions. — No change. 

CLINIC I.— BABY 10 

Dr. F. Raymond Taylor (High Point) 

Age. — Four months. 

History. — Negative, other than that he is a condensed milk 
baby; but since taken to Dr. Taylor last week he has received 
half milk and half water, with 3 percent dextri-maltose, a total 
of 24 ounces a day. Previously he had considerable diarrhea, 
but now his stools seem normal. He's much better, and the 
mother says there is nothing acute the matter with him — simply 
he isn't thriving. 

Temperature.— -97 .6° F. 

Weight. — Nine pounds. 

Examination. — A pale, flabby child. Notice the emaciation. 
Peristalsis can be seen through the abdominal wall. See how 
he puts his fingers into his mouth ! However, we have one good 
sign here. Although he's a puny little fellow, he smiles. Here 
again, as long as we have ruled out tuberculosis, syphilis, nephri- 
tis, and cystitis, and as physical examination is absolutely nega- 
tive, particularly as the history is one of improper feeding, this 
child belongs to the group described as decomposition. 



342 INFANT FEEDING (CHICAGO METHODS) 

Question. — Mother, is he hungry? 

Answer. — Yes, he certainly would take more. 

Directions. — Well, let us give him a little larger quantity. 
Remember, though, it is wiser to offer a mixture not so concen- 
trated as for a normal child. Understand, gentlemen, for such 
children the ideal mixture is albumin milk, but as we can't 
obtain it, we have to use an ordinary milk mixture. This is 
much less efficient. Let us order: 

Milk 15 ounces 

Water 16 ounces 

Dextri-maltose 8 teaspoonfuls 

Seven bottles. 

CLINIC II.— BABY 10 

Age. — Four months one week. (Does not return to Clinic.) 

The nurse says the baby is gaining satisfactorily according to 
an outside scales, and his stools are normal, but he seems hungry, 
and asks if she may increase the diet. 

Weight. — Not obtained. 

Temperature. — Not obtained. 

Discussion. — Gentlemen, whenever a baby is gaining it is 
unwise to increase, especially in these cases of marked decom- 
position, if you cannot see the baby personally. 

Directions. — I don't believe I'd make any change, except 
possibly a slight increase in carbohydrate. As the stools are 
normal, we might give nine teaspoonfuls of dextri-maltose in- 
stead of eight. But let us keep the concentration of the milk 
unchanged. As he's better, we might ease the mother's work 
by ordering five feedings, but under no circumstances change the 
total quantity in twenty-four hours. This means the baby will 
get five feedings of approximately six ounces each. 

CLINIC IV.— BABY 10 

Age. — Four months three weeks. 

Mother says the baby is very sick. He's had " running off " of 
the bowels, seven or eight movements a day, and has been vomit- 
ing a lot. She is sure he lost weight. His food for the past 
three days is not agreeing with him at all, and she wishes some- 
thing else. 



clinics 343 

Weight. — Eight pounds fourteen ounces, showing a consider- 
able loss, for the child weighed nine pounds three weeks ago, and 
had been gaining considerably. 

Temperature. — 97° F. 

Examination. — One glance shows a severe nutritional dis- 
turbance. The skin, which three weeks ago showed returning 
elasticity, fulness, and color, again is inelastic and wrinkly. 
The child has shrunken in every way. There are circles under 
the eyes. The smile is no longer present. He appears anxious 
and miserable. The cheeks are sunken, and generalized rigidity 
is marked. There is no coryza, no bronchitis, no tenderness 
over the ears, no redness in the throat. There is no evidence 
of parenteral infection. Here we have a decomposition baby 
in the state of dyspepsia, almost verging on intoxication. 

Discussion. — Mother says the food is not agreeing with him. 
This statement I am not prepared to admit, for a food upon 
which a child is thriving will not all of a sudden become in- 
jurious without the introduction of some other factor. Here 
our scales are a check, and they told us definitely that up to a 
few days ago baby had been gaining. We must seek some other 
factor, because the very slight change in the diet we made two 
weeks ago would not have had such a marked effect and cer- 
tainly not ten or eleven days after it had been ordered. Indeed, 
we ordered a slight change only, feeling we wouldn't be justified 
in anything more radical without seeing the baby. 

Question. — Mother, has he coughed or sneezed or had a cold, 
or has he been putting his hands to his ears during the last week 
before his trouble started? 

Answer. — No, I haven't noticed that. He coughed once or 
twice and he cried a lot. 

Question. — Did he cry before or after the trouble started? 

Answer. — He cried after. 

Discussion. — Gentlemen, we are strongly tempted to lay the 
blame to this little cough, but I don't think we are justified. 
It was too mild. Still I don't want to censure the milk mixture. 
What other outside factors might be important? 

Question. — The weather hasn't changed much. Are you 
dressing the baby any differently than you did? 



344 INFANT FEEDING (CHICAGO METHODS) 

Answer. — No, during these hot days he wears just his shirt 
and diaper. 

Discussion. — Heat retention, then, can't be a factor. Pos- 
sibly the mother has misunderstood instructions. Let's see 
if she is following the technic of feeding accurately. 

Question. — Mother, tell us exactly how you are feeding the 
baby. 

Answer. — Well, I did just as you told me. I increased the 
food, and gave him six ounces in each bottle as I was directed. 

That is just what we ordered. 

Question. — How often did you give it? 

Answer. — Every three hours. 

Question. — How often? 

Answer. — Every three hours. 

Discussion. — Well, there's the trouble. You remember, 
gentlemen, last week we changed to the four-hour schedule so 
as to make it easier for the mother. We increased the amount 
to six ounces in each bottle, but we did not increase the total 
quantity in twenty-four hours. Mother has been feeding six 
ounces every three hours, which means a total of forty-two 
ounces of food, and we ordered only thirty ounces. So we have 
a severe dyspepsia developing from overfeeding in a decomposi- 
tion baby. There is nothing wrong with the food itself. The 
trouble was too much food. Now we must treat a decomposition 
baby plus a case of severe dyspepsia. I wish we had albumin 
milk. We give nothing but tea until tonight; then one-third 
milk, as — 

Milk 10 ounces 

Water 20 ounces 

Dextri-maltose 4 teaspoonfuls 

Divide this into seven bottles of four ounces each. 

Now, mother, donH give over four ounces at a feeding. 

In a day or two we shall increase the concentration, so that 
by four or five days he'll get — 

Milk 15 ounces 

Water 15 ounces 

Dextri-maltose 6 teaspoonfuls 

Seven feedings. 



clinics 345 

Remember this means four ounces every three hours for seven 
feedings in a day. 

Question by Mother. — In a day do you mean day and night? 
Answer. — Seven feedings in twenty-four hours. 



CLINIC V.— BABY 10 

Age. — Five months. 

Mother is dissatisfied; she says the baby is better, but still 
vomits. Stools are three or four daily. 

Weight. — Nine pounds one ounce, showing a gain of three 
ounces in the week. 

Temperature. — 98° F. 

Examination. — Absolutely no change. 

Discussion.— The child has gained three ounces this week. 
The bowel movements have improved; the child looks better. 
The fact that the weight curve is rising proves that this gastric 
disturbance is not affecting his nutrition. As we get no history 
of parenteral infection, and as our examination is negative, we 
ask again, " can it be possible that the mother still is not follow- 
ing directions?" 

Question. — Mother, tell us exactly how you are feeding the 
baby. 

Answer. — I make double the amount you told me. 

Question. — How much did we tell you? 

Answer. — Milk, 15 ounces; water, 15 ounces; dextri-maltose, 
6 teaspoonfuls, in seven feedings of four ounces. 

Question. — That's right; but why twice the amount? 

Answer. — I've got two babies at home, and so it is easier. 

Question. — Has this child been satisfied with four ounces? 

Answer. — No, he wants more. 

Question. — Don't you sometimes give him a little of his 
brother's bottle, mother? 

Answer. — Well, sometimes I do. 

Question. — How much? 

Answer. — For the last few days I gave him five ounces? 

Discussion. — Gentlemen, here you have the same trouble 
over again. Last week we treated this dyspepsia by food with- 
drawal, and then, as the child was in a state of decomposition, 



346 INFANT FEEDING (CHICAGO METHODS) 

we were particularly careful about increasing. The baby evi- 
dently improved on this treatment, for he gained weight. Now, 
however, mother is pushing the quantity too rapidly, and this 
vomiting is a symptom of another beginning overfeeding dys- 
pepsia. In this case it is unnecessary to withdraw food entirely 
because the baby is gaining. I think if we limit the amount and 
lessen it just sufficiently to stop the vomiting, the result will be 
satisfactory. 

So, mother, if you want the baby to get well you simply must 
follow our instructions. We told you to give seven feedings of 
four ounces, and no matter how much he cries, under no circum- 
stances give him any more. 

Come next week. 

CLINIC VI.— BABY 10 

Age. — Five months one week. 

Mother says the child still vomits, but somewhat less than 
last week. For three days he's had diarrhea, with seven or 
eight watery stools a day, cries, and has colic. 

Weight. — Nine pounds, showing a loss of one ounce in the 
week. 

Temperature. — 99.4° F. 

Examination. — Coryza. 

Discussion. — The weight curve has remained almost hori- 
zontal. The stools show intestinal fermentation. So here we 
have a mild dyspepsia. 

Question. — Mother, how long has the baby had this cold? 

Answer. — For four days. His nose runs all the time. 

Question. — Did he have fever? 

Answer. — Yes, I think he had a little fever. 

Question. — Is he better now? 

Answer. — Yes, he's some better. 

Discussion. — Gentlemen, the history here is typical, i. e., 
a decomposition baby, susceptible as he is to every external in- 
fluence, — to heat, to cold, to infections, — being attacked with a 
slight coryza. One day later he reacts with diarrhea. Such 
children are usually very sick and develop severe nutritional 
disturbances. Here, however, our weight curve makes a rela- 
tively good prognosis. The very slight drop shows us that we 



clinics 347 

have a milder disturbance, only a dyspepsia, and not a severe 
form of that. A loss of one ounce in a few days is of no grave 
significance. 

In such a case, two courses are open. If we could see the 
patient every day, we might leave the milk as it is, or even in- 
crease it slightly, and at the same time withdraw the carbo- 
hydrate. This would give us high protein and low sugar in the 
intestinal tract, i. e., factors favoring putrefaction and overcom- 
ing fermentation. The stools would become constipated, but 
the child would react with a considerable loss of weight, for his 
tissues would feel the loss of the carbohydrate. The same result 
could be accomplished with the use of buttermilk. Then, in a 
day or two, we'd carefully and gradually increase the sugar to 
answer the tissue requirements. In this case, however, co- 
operation in the home is none of the best. We may not see the 
child for two weeks. Total withdrawal of sugar for so long 
would probably be fatal; and again an injudicious and too rapid 
increase, with some fermentation already present in the intes- 
tine, might produce an intoxication. I think the alternative, 
though apparently somewhat reckless, will be safer in this in- 
stance. Let's take into consideration that we may not see this 
patient for some days, and by that time his body tissues will 
need, roughly, three percent carbohydrate. Let's avoid the 
possibility of any error in the home and so order that much at 
once. From this amount, however, some intestinal fermenta- 
tion will doubtless arise, and so we'll try to provide for it by 
ordering putrefactive, alkali-forming reagents, in the hope of 
preventing intestinal damage. Let us add to the above mix- 
ture, curds of one pint of milk, ground very thoroughly through 
a sieve; in addition, a few teaspoonfuls of chalk mixture every 
few hours, and I believe with these alkali-forming agents we 
may increase the dextri-maltose to eight teaspoonfuls, thus 
attempting to give the body tissues the carbohydrate which 
they need. This child is on the border line, however. If at all 
possible, the doctor should see him every few days, and any 
evidence of a further drop in the weight curve must be taken as 
diagnostic of a severer dyspepsia, and typical treatment insti- 
tuted. 



348 INFANT FEEDING (CHICAGO METHODS) 

CLINIC VH.— BABY 10 

Age. — Five and one-half months. 

Mother says the baby is much improved. Bowels three a 
day and still loose, but he seems happy and much more content. 

Weight. — Nine pounds six ounces, showing a gain of six ounces 
in the week. 

Temperature.— 98.8° F. 

Examination. — Looks better. 

Directions. — No change. In a short time we'll add cereals. 

CLINIC I.— BABY 11 
Dr. J. H. Boyles (Greensboro) 

Age. — Nineteen months. 

History. — Family and past history are negative. He's been 
a bottle baby since two months of age, when mother lost her 
milk. Eagle Brand Condensed Milk was given, and he did well 
for some time. For several months he has received cow's milk 
and Graham crackers, potatoes, and soup. For some time he 
hasn't been doing well. He's not thriving; has frequent in- 
digestion, and is very puny. The mother brought him three 
days ago because of severe diarrhea; with 15 to 20 watery stools a 
day. There was no blood in these stools; they were green, 
smelled sour, had mucus and curds. He was feverish, seemed 
losing weight, vomited considerably, and lay in a stupor most of 
the time. He was very sick. 

The doctor ruled out all constitutional disease, parenteral 
infections, tuberculosis, and syphilis. Due to the long history 
of improper feeding and the absence of blood and pus in the 
stools, he thought definite enteral infection unlikely. Urinaly- 
sis was negative, and he made the diagnosis of alimentary in- 
toxication complicating a condition of decomposition. 

Examination. — This shows a child in a miserable state of 
nutrition; feeble, peevish, and irritable. The skin is dry, 
wrinkled, and thin. The musculature is atrophied and rather 
rigid. 

Weight. — Sixteen pounds six ounces. 

Temperature. — 98° F. 



clinics 349 

Discussion. — Gentlemen, although diarrheas in children of 
this age more frequently are due to watermelon, raw sweet 
potatoes, peanuts, anything the child may lay hands on, I think 
the diagnosis in this instance is absolutely correct. Here is 
a history of decidedly improper feeding, leading to decomposi- 
tion. The primary gain on condensed milk was due, of course, 
to the sugar, and additional feeding of Graham crackers and 
potatoes furnished still more carbohydrate. There has been 
nothing to cover the child's demand for protein, for salts, pos- 
sibly for fat. Soups, you know, have no food value other than 
the salts they contain. 

Question by Dr. Beat. — Do you mean to say that soups are not 
nourishing? 

Answer. — The ordinary soup which we offer has no food value; 
it contains simply the extractives of the meat and leaves the 
nourishing part behind. We feed soups to supply salts and to 
stimulate the appetite. Children like them, but as regards 
food value, they are unimportant. 

The treatment the doctor ordered in this case seems absolutely 
perfect. He ordered tea for twenty-four hours. Following 
this, in the absence of albumin milk, and because a child of this 
age, and even as sick as this child was, unquestionably can tol- 
erate mixtures of cow's milk, the doctor ordered a mixture of — 

Milk 15 ounces 

Water 15 ounces 

Dextri-maltose 6 teaspoonfuls 

On this treatment the child is better and happier and the 
diarrhea has improved greatly. 

But, gentlemen, notice how he keeps his hands in his mouth; 
notice his puny size, his thin, flabby, inelastic skin. Notice 
the extreme emaciation and rigidity of the muscles characteristic 
of these children on one-sided carbohydrate diets (this is a 
typical picture of Czerny's starch injury). See how the emacia- 
tion reveals general adenopathy, as in tuberculosis! The rig- 
idity is so marked as to make us think of Little's disease. These 
conditions the doctor has ruled out, and the weight of sixteen 
pounds six ounces shows the miserable state of nutrition, and 
confirms our diagnosis of decomposition. Here, then, we have 



350 INFANT FEEDING (CHICAGO METHODS) 

a child in the state of decomposition who, for some unknown 
reason, developed an intoxication. This complication has been 
successfully treated, and now it is up to us to correct the state 
of decomposition. As the acute disturbance is past, let us give 
more food. 

Directions. — We'll keep the milk in dilute concentration. 
Then we safely can give more carbohydrate in a non-ferment- 
able form : as farina, corn-starch, arrow-root, mush, tapioca, or 
Cream of Wheat. We may give a little mashed potato. I 
think I'd omit oatmeal, which is the most easily fermentable 
cereal. To supply salts we add vegetable purees. To supply 
protein, and in this case also to keep the intestine alkaline, we 
add pure cottage cheese, or, if this is not obtainable, simply the 
curds of milk. In a baby of this age we may offer finely scraped 
meat, such as a chicken or lamb-chop. We may add custard 
and zwieback. I think I would feed this child a little oftener 
than the normal schedule, namely, every three hours, — seven 
feedings in twenty-four hours, — and remember, increase very 
slowly and cautiously. By no means give him everything in 
one day, or large quantities of any particular food. 



CLINIC II.— BABY 11 

Mother says the child is much better and happier. His 
bowels move only three times daily. 

Weight. — Seventeen pounds ten ounces, showing a gain of 
one pound four ounces in the last week. 

Temperature.— 98.8° F. 

Examination. — Looks better, brighter, and happier. 

Discussion. — Considering the above gain in weight, we don't 
need to complain about the therapeutic results in this case. 
The child now is eating a little egg, potato, meat, Graham crack- 
ers, cereals, and milk, and seems on the road to complete re- 
covery. 

Directions. — Put him on five feedings. 

CLINIC III.— BABY 11 

Mother sends in report that baby is doing nicely. 



CLINICS 351 

CLINIC I.— BABY 12 
Dr. H. H. Ogburn (Greensboro) 

History. — Baby is three months old. Family and past his- 
tory negative. The baby was breast fed every two hours since 
birth; was always hungry, always fretful, never thriving; he 
has no diarrhea, but is puny and not gaining. 

Temperature. — 97.4° F. 

Weight. — Six pounds twelve ounces. 

Examination. — This shows a baby of the typical decomposi- 
tion type, with wrinkled skin and cold hands and feet. 

Diagnosis. — Although the appearance is that of decomposi- 
tion, we have learned in breast-fed children to establish the 
diagnosis rather of inanition. 

Directions. — Having, by examination and tests, ruled out 
conditions other than feeding, we'll treat this child as a case of 
inanition. We'll order seven nursings in twenty-four hours, the 
mother to allow the child five minutes for the breast and then 
ten minutes for the bottle. We don't know how much this 
child will take in each bottle, but, as a guess, two ounces. This 
would make a formula of, roughly — 

Milk 7 ounces 

Water 8 ounces 

Dextri-maltose 4 teaspoonfuls 

Seven bottles. 

CLINIC II.— BABY 12 

Age. — Three months one week. 

Mother says the child is better, cries less, and seems happier. 
The bowels are still loose, however — about three a day. 

Weight. — Seven pounds four ounces. Gain of eight ounces in 
a week. 

Temperature.— 97.8° F. 

Examination. — Looks better. 

Directions. — As this is such an excellent gain in this puny 
child, we'll make no change. 



352 INFANT FEEDING (CHICAGO METHODS) 

CLINIC m.— BABY 12 

Age. — Three months two weeks. 

Mother says the baby has four or five green, watery bowel 
movements each day. He doesn't desire much food and has 
been peevish and irritable. 

Weight. — Seven pounds four ounces, showing no gain this 
week. 

Temperature.— 98.2° F. 

Examination. — Negative. There is no parenteral infection, 
and the child doesn't look unhappy. The skin, however, isn't 
quite as fresh looking as last week, and there are suggestions of 
rings under the eyes. 

Discussion. — Gentlemen, here we have one of the conditions 
in which perplexity may arise. Are these watery, green bowel 
movements of significance or are they not? The weight curve 
during this week is perfectly straight. Is this due to under- 
feeding, and will the curve and stools improve upon increase of 
diet, or have we a beginning dyspepsia? The fact that he 
doesn't desire food makes us cautious, and I think it wiser to 
hold him as he is. The fact that he gained well last week — 
eight ounces — makes us in no particular hurry, and if this be 
an incipient dyspepsia, due to some outside factor, — possibly a 
cystitis, — it is wiser to make no change for a few days and note 
the reaction. Meanwhile we await urinalysis. 

Directions. — Mother must be very careful to feed the baby just 
exactly as we directed, and if he doesn't want all his food, take 
the bottle from him. Don't force it! 

Bring him next week. 

CLINIC IV.— BABY 12 

Age. — Three months three weeks. 

Mother says baby is much better but seems hungry. Stools 
are three a day and a little loose. 

Weight. — Seven pounds twelve ounces, showing a gain of 
eight ounces in the last week — really in two weeks. 

Temperature. — 98° F. 

Examination. — Child looks fresher. Urine reported negative. 

Directions. — As there was no gain in the previous week, and 



clinics 353 

as he seems hungry and is well in every other respect, I think we 
are justified in increasing slightly. Let's give, in addition to 
the breast, 

Milk 9 ounces 

Water 9 ounces 

Mellin's Food (as the mother cannot get 

dextri-maltose) 6 teaspoonf uls 

Seven feedings. 

CLINIC VI.— BABY 12 

Age. — Four months one week. 
The baby is happy in every way and doing nicely. 
Weight. — Eight pounds eight ounces, showing a gain of twelve 
ounces in two weeks. 
Temperature.— 98.6° F. 

Examination. — Child looks bright, happy, and contented. 
Directions. — No change. 

CLINIC I.— BABY 13 
Dr. Ed. King (StatesviUe) 

Age. — Three months. 

History. — Family and past history negative. Twelve other 
children living and well. The baby is brought for vomiting, 
which has persisted since birth. He gets the breast every half- 
hour. 

Temperature. — 97.6° F. 

Weight. — Nine pounds. 

Examination. — A fine, healthy, happy baby. 

Discussion. — Persistent vomiting since birth makes us think 
of pyloric stenosis. However, if such were the case, the child's 
nutrition would be markedly affected. One look rules this out. 
Vomiting from parenteral infections wouldn't have persisted so 
long. I'm inclined to think the vomiting is due to the improper 
technic of feeding. Perhaps the baby is underfed and mother 
puts him to the breast every half-hour to appease him. Of 
course, continual insult to the stomach makes it rebel. 

Directions. — Let us put him on regular nursings — twenty 
minutes every three hours, seven feedings in twenty-four hours — 
and await the reaction. 
23 



354 INFANT FEEDING (CHICAGO METHODS) 

CLINIC II.— BABY 13 

Age. — Three months one week. 

Mother says baby has ceased vomiting, but is very consti- 
pated, fretful, and peevish. 

Weight. — Nine pounds, showing no gain this week. 

Temperature.— 97. ti° F. 

Examination. — No change. 

Discussion. — Failure to gain, with no vomiting, no diarrhea, 
and with constipation, establishes the diagnosis of inanition. 

Directions. — Add after nursing: 

Milk 4 ounces 

Water 4 ounces 

Sugar 1 teaspoonf ul 

Seven bottles. 

CLINIC m.— BABY 13 

Age. — Three months two weeks. 
Baby still hungry — no vomiting. 

Weight. — Nine pounds two ounces, showing a gain of two 
ounces in a week. 
Directions. — Increase diet to — 

Milk 8 ounces 

Water 8 ounces 

Sugar 3 teaspoonf uls 

Seven bottles. 

CLINIC IV.— BABY 13 

Mother sends in report that baby is doing very well indeed 
and seems satisfied and contented. 

CLINIC I.— BABY 14 
Dr. A E. Bell (Mooresville) 

Age. — Four months. 

History. — Family and past history negative. Baby was 
breast fed for one month. Mother lost her milk and gave 
Mellin's Food with cow's milk. Due to work in the fields, she 
has never given him proper care, leaving him to grandmother, 



clinics 355 

who doesn't know definitely the details of the diet. The baby 
was brought to Dr. Bell a few days ago on account of severe 
diarrhea, with green, watery, sour-smelling stools containing 
mucus and curds. Although this was an acute attack, the child 
had been ailing for a long time. He is better now, but still very 
weak. 

Weight. — Seven pounds — less than when he was born. 

Temperature. — 97° F. 

Examination. — Physical examination other than extreme 
emaciation and weakness is negative. Pirquet and urinalysis 
are negative. The family history gives no reason for suspecting 
lues. It is a case of marked decomposition. 

Directions. — In such an extreme case we prefer infinitely 
breast milk or albumin milk. An ordinary milk mixture is far 
less efficient. Indeed, I doubt whether we shall accomplish 
much. 

Question. — Grandmother, is there any possibility of getting 
any breast milk from your neighbors? 

Answer. — Yes, Mrs. Miller just had a new baby and I might 
get a little from her. 

Question. — Do you suppose that you could get an ounce every 
two hours? 

Answer. — I think so. 

Well, then, give the baby an ounce at 6, 8, 10, 12, 2, 4, 6, 8, 
10 o'clock and once or twice during the night. Be sure to warm 
the milk to body temperature before using, and feed the baby 
absolutely regularly. Don't let him have the bottle over ten 
or fifteen minutes. 

Discussion. — Gentlemen, this child is sick enough to need 
stimulation. He would be better in a hospital. Failing such, 
I doubt if we'll be able to accomplish much in the home. 

We know that proper care and proper nursing are equally 
as important as certain formula?. I have grave fears, -as you 
yourselves probably have, — after noticing grandmother's hostile 
demeanor, — that our instructions may not be carried out. When- 
ever grandmother looks skeptical, she probably intends intro- 
ducing methods of her own. I don't believe she approved of 
our advice. 



356 INFANT FEEDING (CHICAGO METHODS) 

CLINIC H.— BABY 14 

Age. — Four months one week. 

Grandmother states baby is better, that his bowels are all 
right and his appetite good. 

Weight. — Seven pounds four ounces, showing a gain of four 
ounces in one week. 

Temperature. — 98° F. 

Examination. — No change. 

. Discussion. — Gentlemen, you remember last week we dis- 
cussed the importance of care in the home, and wondered how 
frequently our directions really were carried out. It always is 
interesting to learn if baby really has improved on our feedings, 
or if some change of diet which the nurse never admits is the 
fundamental reason. 

Question. — Grandmother, tell us just exactly what you gave 
the baby. 

Answer. — Well, doctor, to tell the truth, I was able to get 
more breast milk from Mrs. Miller than I thought; so I gave 
the baby four ounces instead of one. 

Question. — How often did you give this, grandmother? 

Answer. — Well, I tried to give it every two hours. 

Question. — You don't mean that you gave the baby four 
ounces every two hours? 

Answer. — Perhaps not every two hours, but somewhere near 
there. 

Question. — How much are four ounces? 

Answer. — I didn't measure exactly, but Mrs. Miller said she 
thought there were four ounces. It quarter filled my glass. 

Discussion. — Gentlemen, you see how many factors come into 
infant feeding, and how often we draw absolutely false conclu- 
sions. In this instance grandmother says she offered four ounces, 
but probably the baby got only two. One fact remains, how- 
ever, the baby gained. For this let us be grateful; so, as long as 
he's gaining, we'll be justified in violating dogmatic routine and 
continuing the amounts which grandmother offers. I believe 
you will agree with me that in this case it is impossible to demand 
an exact routine. So, grandmother, as long as the baby is gain- 
ing, feed him as you are doing, but try to be regular, and measure 



clinics . 357 

in the bottle just how much you are giving, because that will 
help us greatly. Try to feed him every three hours — 6, 9, 12, 
3, 6, 9 o'clock, and once during the night, and tell us next week 
how many ounces he takes, as you measure it in your bottle. 



CLINIC m.— BABY 14 

Age. — Four months two weeks. 

Grandmother says the baby is better. 

Weight. — Eight pounds, showing a gain of twelve ounces in 
the week. 

Temperature.— 98.4° F. 

Examination. — Negative. Notice how much fresher and hap- 
pier he looks, and, above all things, notice the returning elas- 
ticity to the skin and the decided change in color. This child 
is doing nicely. 

Question. — Grandmother, how are you feeding the baby? 

Answer. — I am feeding him just exactly as you told me. He 
seems satisfied, and I think he's much better. 

He gets three ounces each feeding. 



CLINIC IV.— BABY 14 

Age. — Four months three weeks. 

Grandmother says the baby is doing as well as can be ex- 
pected. He seems more cheerful, but she can't see much change 
in his weight. Bowels move two or three times a day. 

Weight. — Eight pounds four ounces, showing a gain of four 
ounces. 

Temperature.— 98.6° F. 

Examination. — Baby looks better. 

Discussion. — Well, gentlemen, we didn't expect a very notice- 
able change in such a tiny baby, but the scales show a gain of 
four ounces. This isn't bad. 

Question. — Grandmother, what have you been giving this 
week? 

Answer. — Well, I can only get breast milk once in a while, 
and so I gave five ounces whenever I could get it, and the rest 
of the time condensed milk. 



358 INFANT FEEDING (CHICAGO METHODS) 

Question. — How much breast milk did you give him in twenty- 
four hours? 

Answer. — I don't think I got much more than five or ten 
ounces. 

Question. — And the rest of the feeding was condensed milk, 
was it? 

Answer. — Yes. 

Question. — How much in each bottle? 

Answer. — I guess about five ounces. 

Discussion. — You see how careful we must be at all times. 
If we hadn't learned this, we should have attributed this gain 
to breast milk and would have been pleased. You remember 
the dangers of condensed milk — how a child gains temporarily 
from the high amount of carbohydrate, but that this gain repre- 
sents water-logging of the body rather than true gain in tissue 
substance. So, although he apparently put on four ounces, we're 
not satisfied. If we must use artificial food, let us use a regular 
milk mixture. 

Doctor, will you explain to grandmother during the week the 
dangers of condensed milk feeding and let us figure on a milk 
mixture of — 

Milk , 10 ounces 

Water 22 ounces 

Dextri-maltose v 8 teaspoonfuls 

Seven bottles. 

This will make seven feedings in twenty-four hours, of four 
and one-half ounces each — a little more than I ordinarily would 
order, but as grandmother has been giving five ounces every 
three hours, I think we're safe. I'd give just as much breast 
milk as possible at each feeding. Then offer a bottle for ten 
minutes. Let him take as much as he wishes, and after ten or 
fifteen minutes, if he hasn't finished, take it away and make 
him wait until the next feeding time. 



CLINIC V.— BABY 14 



Age. — Five months. 

Grandmother says he is better, but hungry. 



clinics 359 

Weight. — Eight pounds eight ounces, showing a gain of four 
ounces in the week. 

Temperature.— 98.4° F. 

Examination. — No marked change. 

Discussion. — Gentlemen, in a child as poorly nourished as 
this one we mustn't push feedings too rapidly, particularly 
where we're not sure of the nursing cooperation in the home. 
I believe as long as he's gaining we should leave him for two or 
three days, and then, if he seems very hungry, we might in- 
crease to perhaps — 

Milk 13 ounces 

Water 19 ounces 

Dextri-maltose 8 teaspoonfuls 

L Seven bottles. 

and perhaps toward the end of the week — 

Milk 15 ounces 

Water 17 ounces 

Dextri-maltose 8 teaspoonfuls 

Seven bottles. 



CLINIC VI.— BABY 14 

Age. — Five months one week. 

The baby had a diarrhea this week, but now bowels move 
only once or twice a day. Careful questioning shows that grand- 
mother overfed the baby, and of herself removed food, thus 
treating successfully the resulting dyspepsia. 

Weight. — Eight pounds four ounces, showing loss of four 
ounces during the week. 

Temperature. — 98° F. 

Examination. — No change. 

Directions. — Continue to feed the baby as ordered, giving — 

Milk 15 ounces 

Water 17 ounces 

Mellin's Food (as grandmother can't get dextri- 
maltose) 1 ounce 

Seven bottles. 



360 INFANT FEEDING (CHICAGO METHODS) 

CLINIC VII.— BABY 14 

Age. — Five months two weeks. 

The diarrhea has gone, and the bowels move once a day and 
are hard. The baby is hungry, however. 

Weight. — Eight pounds three ounces, showing a loss of one 
ounce during the week. 

Temperature. — 98° F. 

Examination. — No change. 

Directions. — Increase the feeding to — 

Milk 18 ounces 

Water 16 ounces 

Mellin's Food 9 teaspoonf ills 

Seven feedings. 

CLINIC Vm.— BABY 14 

Child much better. 

Weight. — Eight pounds twelve ounces, showing a gain of nine 
ounces in the week. 
Directions. — No change. In a few days start cereal. 

CLINIC I.— BABY 15 
Brought by Dr. W. P. Knight (Greensboro) 

Age. — Two years two months. 

History. — Family and past history negative. The complaint 
is very marked constipation. The child wouldn't have a bowel 
movement oftener than every three or four days if castor oil 
or enemas weren't given continually. 

Weight. — Not taken. 

Temperature— 98.8° F. 

Examination. — Negative. 

Discussion. — Gentlemen, in trying to diagnose the cause of 
this"condition let us think of the simplest things first. Let us 
see exactly what baby has been eating. 

Question. — Mother, how do you feed the baby? 

Answer. — I give him meat, one and sometimes two eggs a day, 
a little broth, some toast, once in a while some corn-starch or 
Cream of Wheat, and once or twice a week a baked apple. 



CLINICS 361 

Question. — Don't you give him anything"else? 

Answer. — No. 

Question. — Don't you give him any vegetables? 

Answer. — No, my book on feeding said I shouldn't use any 
vegetables until he was over two years of age. 

Discussion. — Gentlemen, you see how simply we meet many 
of the problems in pediatrics? You see the value of a little 
simple physiology? Remember, in the early lectures we spoke 
of fermentation and putrefaction. Meat and eggs, which form 
a large part of this baby's diet, are protein and cause an alkaline 
intestinal reaction. The carbohydrate which the baby gets is 
of the starchy type, and normally will not produce much fer- 
mentation. Again, there are no vegetables — not enough cellu- 
lose to leave a residue in the intestines. I think the treatment 
is to put this child on a perfectly full diet, perhaps reducing the 
meat and eggs slightly, giving more cereal, particularly oatmeal. 
By all means give plenty of vegetables, even the coarser ones, 
such as mashed cabbage and turnips. Give baked apple or 
apple-sauce every day, all kinds of stewed fruits, and, in short, 
feed the baby almost everything that you would feed an adult, 
with the exception, of course, of the very heavy things, and with 
the provision that whatever you give must be cut up fine. 
I would lay particular emphasis upon vegetables and stewed 
fruits. Graham crackers are considered laxative. 

Now, of course, this baby won't react tomorrow, and so, until 
we get him adjusted, he will be constipated. Under these cir- 
cumstances let him go for perhaps two days, and then give an 
oil enema. Under no circumstances give him any more pur- 
gatives. 

A valuable aid in children of this age is a combination of raw 
prunes, dates, figs, and raisins. These are put through a meat- 
grinder, or finely chopped in a chopping bowl, and formed into 
little candy balls. Roll them in a little powdered sugar and they 
look like candy. 

In this case we may need some malt soup extract and may be 
some mineral oil also. 



362 INFANT FEEDING (CHICAGO METHODS) 

CLINIC I.— BABY 16 
Brought by Dr. C. W. Woodson (Salisbury) 

Age. — Fifteen months. 

History. — Negative except for the following: The child re- 
ceived the breast for fourteen months, plus a mixed diet from 
the eighth. After thriving until ten months he developed 
measles and whooping-cough. During the following weeks he 
lost weight and became puny, but his bowels were all right. 
Then he got a severe diarrhea, with some blood in the stool. 
The family physician treated him with broth and albumin water 
for five days. Although the diarrhea stopped, he got much worse 
on this diet. Another physician was called, who ordered 'a full 
diet. The child again grew worse, vomited, had severe diarrhea, 
and lost rapidly. The parents, in desperation, took him to a 
neighboring city. Here for four days the doctor ordered large 
quantities of oatmeal water and buttermilk. He received noth- 
ing else during that time and gained rapidly. Two or three 
days ago another doctor was called. Although the child had 
gained at an enormous rate, he was very, very sick. He was 
suffering severe diarrhea, temperature was 97° F., and the whole 
body was edematous. The last physician ordered albumin milk. 
On this he has lost much of what he gained. 

Temperature. — 97° F. 

Weight. — Ten pounds. 

Examination. — This shows a terribly emaciated child — the 
worst we have seen. Diffuse rales are present throughout the 
chest. 

Discussion. — Gentlemen, is this a case of decomposition due 
to various factors, or is it miliary tuberculosis? In favor of 
tuberculosis is the history of measles and whooping-cough and 
the clinical picture, with the rales throughout the entire chest. 
Against this diagnosis are the absence of an enlarged liver and 
spleen and the absence of dulness upon direct percussion over 
the spine — from enlarged bronchial glands. A Pirquet here 
would not help us because, if this is tuberculosis, it is of the 
miliary type and would give a negative reaction. The only sure 
way is to introduce a cotton swab into the larynx, obtain sputum 
when the child coughs, and make smears. 



clinics 363 

In favor of decomposition of the mixed type we have the 
history of all sorts of irregularities in feeding, improper diets, 
starvation, recently one-sided carbohydrate feeding, plus the 
secondary influences of parenteral infections, as measles and 
whooping-cough, and even possibly definite enteral infection 
when blood appeared in the stools. The cough might simply be 
a bronchitis secondary to the child's weakened condition. 

The subnormal temperature doesn't help us, for it may be 
present in either alimentary decomposition or in the collapse 
of a miliary tuberculosis. 

In either case, however, whether it is a decomposition due to 
tuberculosis or to alimentary factors, the child must be fed. 
Our feeding technic will be the same as in decomposition. 

Directions. — Let us keep him on albumin milk with 3 percent 
dextri-maltose. Let us offer protein in the form of soft-boiled 
egg, cottage cheese, curds of milk. Let us offer carbohydrate, 
as mashed potato, zwieback, and corn-starch. 

Of course, remember to be very, very careful as regards quan- 
tity, and certainly not start more than one new food on the same 
day. I believe he is so sick we might try three-hour feedings. 

Give the child all the water he wants to drink, and you may 
have to stimulate him. 

Let us see him next week if he is still with us. 



CLINIC H.— BABY 16 

Present Age. — Fifteen months one week. 

Present Weight. — Twelve pounds nine ounces, a gain of two 
pounds nine ounces in one week. 

Mother says the child is improved in every way. He is 
brighter, happier, his voice is stronger, and sometimes he smiles. 
She has noticed his great gain. He likes his food and wants 
more. 

Examination. — Shows a decided improvement. There is a 
suggestion of returning elasticity to the skin, and the muscles, 
too, begin to feel more like the normal. Doctor reports smears 
negative for tubercle bacilli. 

Discussion. — Gentlemen, from the standpoint of our course, 
this case makes a most excellent conclusion. Within the last 



364 



INFANT FEEDING (CHICAGO METHODS) 



months has arisen almost every complication possible in the 
course of infant feeding. Let us picture the course of this child 
by the following curve (Fig. 38) : 





l to ri , - h - 


April. 


May. 


July. 


August, 






£0 ibe. 














16 lbs, 








■s a* 


• 

4J 




A. 






16 lb8. 


** 

o 

4> 


-ft— 


N 


4* 
O 


\ a 




S/\ 




14 lbs, 


1 


I 

S 


l 


i 
O 






/I \ 




12 lbs 


3 


o 


1 
5 


a 

1 


I 


>v a 




/ & \ 
' 9 - \ 




10 lbs 


& 


« 


ft 


H 


1 


o 

& 




/ a \ 



















Fig. 38. 



He was doing nicely until he suffered a parenteral infection. 
Due to this, his nutrition suffered and he ceased to gain. A 
severe diarrhea complicated the picture. We can't say whether 
this was an infectious diarrhea or one resulting from the paren- 
teral infection. The presence of bloody stools makes us suspect 
the former. The weight curve suffered. The physician treated 
the stool and ordered nothing but a starvation diet for five days. 
The stool improved, but the factor of severe hunger, added to 
the previous injuries, undoubtedly was sufficient to reduce the 
child to a condition of decomposition. Now, the physician not 
recognizing the fundamentals of the case, ordered a full unre- 
stricted diet. This additional insult reduced the child still fur- 
ther and he was taken out of town. In a neighboring city, a 
mixture high in water, carbohydrate, and salt was ordered. 
The gain in weight was phenomenal, but, gentlemen, this gain 
in weight was not one of true tissue substance, but was one of 
water. The condition of decomposition was not cured, but was 
masked. The water-logging of the body was extreme — great 
enough to produce a marked edema. The water, however, was 
bound only very loosely to the tissues. The baby was in a criti- 
cal condition, with subnormal temperature and slow, feeble 



clinics 365 

pulse. The feeding then ordered, i. e., albumin milk, a mixture 
low in salts, low in sugar, just the reverse of the previous, caused 
a complete reversal of the reaction. The organism squeezed out 
the excess of fluid with which it previously had been filled, and 
the baby was in a condition identical to that when he left town. 
The feeding instituted last week, taking into consideration the 
needs of the body tissues, answering them with a combination not 
injuring the intestinal tract, has apparently worked wonders. 
I believe this child will recover. I am very proud of this result, 
gentlemen, and I should advise you to copy this curve and study 
it carefully. In it you have a summary of our entire course. 

Question by Dr. Flippen. — Before concluding this part of the 
course, would you mind stating precisely once more just what 
significance you place upon stool examination? 

Answer .—Gross examination of the stool will aid us, first, in 
distinguishing the infectious from the nutritional types of diar- 
rhea. The infectious types usually are associated with blood, 
mucus, pus, and rather small, solid contents of the stool. The 
nutritional types only rarely show blood or pus. Dysentery 
causes alkaline stools; nutritional diarrheas, usually acid. Hav- 
ing ruled out infectious disturbances, the condition of the stool, 
whether constipated or diarrheal, is of value. 

The constipated stool in many cases may mean insufficient 
food or insufficient fermentable carbohydrate, allowing putre- 
factive processes to predominate, or may mean simply insuffi- 
cient residue in the intestinal tract from excessive resorption 
of the food. It must be considered only in connection with the 
child's weight curve. If the child is gaining, the stool has little 
significance. 

The diarrheal stool usually signifies excessive fermentation in 
the child's intestinal tract. Whether this fermentation be due 
to a high carbohydrate-whey mixture, to parenteral infec- 
tions, to heat, to overfeeding, or to other factors, our history 
and examination will disclose. I believe I've made the com- 
parison of diarrheal stools to coughs. If the baby coughs once or 
twice a day, we accept this as evidence of irritation of the re- 
spiratory tract, but don't get excited. If he coughs more fre- 
quently but has no fever and is still subjectively well, we assume 
that the respiratory irritation is worse, but still are not alarmed, 



366 INFANT FEEDING (CHICAGO METHODS) 

because the child himself is not suffering. However, when he not 
only coughs severely, but also shows other reactions, as fever 
and general disturbance, then we know that the infection is 
sufficient to affect the baby as a whole. So it is with these diar- 
rheal stools. When the child's weight curve is unaffected, when 
the child clinically is well, we pay little attention. Indeed, we 
know these stools may be symptoms even of underfeeding, but 
if the child, on the other hand, appears sick, shows changes in 
his general behavior and conduct, is fretful, and, above all things, 
shows changes in the weight curve which are so significant of 
the baby's general condition, then we know that the conditions 
in the intestinal tract are sufficient to affect the baby as a 
whole. 

So, gentlemen, stool examination in these conditions is of 
importance, but it is of importance only as a symptom, and 
must be studied not by itself, but only in connection with baby's 
history, present condition, general conduct, and, by all means, in 
connection with his weight curve. 



CONCLUSION 

Gentlemen : This concludes the main chapters of the course. 
These lectures and clinics have leaned possibly a little more to 
the scientific, a little less to the practical. This was absolutely 
intentional on my part. To attempt to teach you, with your 
years of experience the practice of medicine would be absurd. 
You know better than I the little devices, the various forms of 
psychotherapy, that sustain and satisfy anxious patients. In 
inanition, if the mother thinks her breast milk not good, satisfy 
her by obtaining a specimen for examination. In a case of 
overfeeding, if the child vomits, give a little placebo, besides 
correcting the diet. In dyspepsia order a mild mixture for the 
bad stools. Only in families of the highest type can you practise 
your profession, without some sort of a prescription. In the 
city, as well as in the country, patients want medicine. In 
this course, however, I have omitted all these details because I 
wanted to show you the clear, distinct reactions. The disap- 
proving glances of our good nurses, the disappointment of the 
parents, and even your oWn criticisms have not escaped me, 



clinics 367 

but I paid no heed, for I wanted to teach you what I consider 
the truth. I wanted to feel that after the conclusion of this 
course no one would be justified in completely overlooking some 
of the essentials in diet and saying, " Such and such a result was 
due to a stomach washing, a colonic flushing, a dose of castor 
oil, or what not, given coincident ally with the change of food." 
We have attempted, one might say, a laboratory course, un- 
trammeled by any factors which might cloud the pictures. 
Usually a haze separates us from our patients, a haze made 
of false conclusions derived from superficial examinations and 
from blind adherence to antiquated texts; a haze invoked by 
superstitious grandparents, and, as I understand it, even by 
some of your newspapers and by some of your clergy in their 
unthinking recommendation of proprietary and secret remedies. 
I have tried to clear away this mist; to reveal the patient clear 
and distinct before you; to show you the truth, as I see it. 
Having mastered the science and truth of medicine, you may, if 
necessary, adopt the various devices of practice with impunity. 
Use them, but don't let them blind you. 



INDEX 



Abnormal breast-fed baby, 25 

breast milk, 23 
Absorption, 20 

toxic, 22 
Acetic acid, 20 
Acetone, 99 

in urine, conditions in which 
found, 99 
test for, 99 
Acetonuria, 99 
Acid, acetic, 20 

butyric, 20, 156 

intoxication, acidosis in, 100 

lactic, 153 
Acidity in intestine, 20, 21 
Acidosis, causes, 98 

definition, 98 

etiology, 101 

in acid intoxication, 100 

in diarrhea, 79 

treatment, 101-103 

types peculiar to children, 100 

usual symptoms, 101 
Acids, fatty, 164 
Adrenalin, 218 
Adulteration of milk, 154 
Agar-agar, 75 
Albumin in milk, 19 

milk in treatment of decomposi- 
tion, 233 
of intoxication, 219 
preparation of, 220 

technic of Langstein and 
Meyer, 235 
Albumins, 153 
Alimentary intoxication, 214 



Alkali as prevention of curd forma- 
tion, 47 
in treatment of acidosis, 102 
Alkalinity in intestine, 20, 21 
Alkalis, 164 
Amino-acids, 163 

salts of, 20 
Apple, 54 

Artificial feeding, 27 
certified milk in, 27 
modification of milk in, 29 
gravity method, 30 
whole method, 30 
of normal infant, 256 
pasteurized milk in, 28 
sterilized milk in, 28, 29 



Babcock quantitative test for fat 

in milk, 154 
Baby, average, caloric needs of, 21 

premature, 56-58 
Bacillus, dysentery, 83 

gas, 83 

streptococcus, 83 
Bacteria, action of, upon carbohy- 
drates, 208 

in intestine, 20, 208 

in stools, 173 
Bacterial growth in milk, 156 
Barley jelly, 46 

water, 45 
Beef -juice, 53 
Bile, 20 

Bismuth in diarrhea, 81, 87 
Boiled milk, 160, 162, 250, 254, 255 



42 



369 



370 



INDEX 



Bowels of new-born baby, 22 
Breast and bottle feeding mixed, 
case illustrating, 142 
feeding, 21, 270 

amount taken in twenty-four 

hours, 23 
appearance of milk, 272 
contra-indications for, 26, 270 
difficulties in, from local changes 
in breast, 271 

from standpoint of child, 272 
during menstruation, 26, 274 
during pregnancy, 26, 274 
first few weeks, 22 

of newborn baby, 22 

twenty-four hours, 22 
intervals for, 22 
modification of milk, 24 
quantity of milk, 24, 274, 275 
regularity of, 22 
second day, 22 

stimulation of breasts, 24, 273 
swallowing of air during, 26, 277 
weaning, 26 
weight in, 23 
wet-nurse, 27, 273 
milk, abnormal, 23 
calcium in, 169 
composition of, 41, 155 
in alimentary intoxication, 221 
in nutritional disturbances, 198, 

201 
modification of, 24 
quantity of, 24, 274, 275 
scarcity of , 24 
stimulation of production of, 24, 

273 
time of appearance, 22, 272 
Breast-fed baby, abnormal, 25 

abnormal bowel movements in, 

281 
colic of, 25 

treatment of, 26 



Breast-fed baby, constipation in, 
282 
dyspepsia in, 288 
etiology, 288 
symptoms, 288, 290 
treatment, 290 
inanition in, 284 
diagnosis, 286 
etiology, 285 
prognosis, 286 
treatment, 287 
irregular feeding intervals, 26 
normal, gain in weight of, 24 
nutritional disturbances of, 25, 

280 
stools of, 25 

substitute feedings for, 25 
undernourishment of, 25 
vomiting in, 280 
Bulgar tablets, 82 
Buttermilk, 220 

composition of, 48 
Butyric acid, 20, 156 



Calcium, 112, 114, 164 
chlorid, 114, 115 
in breast milk, 169 
in cow's milk, 169 
lactate, 114 
Calomel, 75 

in infectious diarrheas, 252 
Caloric needs of average baby, 21, 
176 
production of fat, 21 
of protein, 21 
of sugar, 21 
value of foods, 176 

formula for calculating, 40 
Calorie, 39 

definition, 21 
Cane-sugar, 44 
Carbohydrates, caloric value of, 176 



INDEX 



371 



Carbohydrates, digestion of, 165 

forms of, 165 

functions performed by, 166 

in milk, 153 

need of, in nutritional disturb- 
ances, 200 

relation of, to water in body, 167 
Care of nursing mother, 21 
Carpopedal spasm, 113 
Casein, 45, 46, 153 

breast-milk, 19, 156 

cow's milk, 19, 156 
Castor oil, 22, 75 
Certified milk, 27, 159 
Chapin dipper, 32 
Chicken soup, 53 
Chloral in diarrhea, 87 
Chvostek's sign in spasmophilia, 113 
Clinics, 116-144; 293-367 
Colic, 25 

Composition of milk, 19 
Condensed milks, 50, 51 
Constipation, 72, 194, 195, 196 

causes of, 72 

diet in, 74 

drugs in treatment, 74, 203 

in disturbances of breast-fed, 283 

laxatives in, 74 

sugar in treatment, 202, 203 
Convulsions in spasmophilia, 113 
Craniotabes, 106 

Cream, gravity, composition of, 32 
Curds, 156 

casein, 46 

in stool, 160 

methods for preventing, 47 



Decomposition, clinical picture, 
224 
diagnosis, 230 

gastro-intestinal symptoms, 226 
infection in, 227, 228 



Decomposition, metabolism in, 229 
treatment, 233 

in older children, 239 
Dextrins, 44, 45, 165 
Diacetic acid in urine, test for, 99 
Diarrhea, acidosis in, 100 
causes, 205, 208 

chronic fermentative, feeding of 
eighteen-months-old baby with, 
case illustrating, 128 
difference between infectious and 

fermentative, 88 
fermentative, 77 
diet in, 80 

due to protein, 82, 83 
in small baby, case illustrating, 

134 
stools in, 78 
treatment, 80 
gas bacillus type, 87 
diet in, 87 
test for, 88 
high sugar diet as cause of, 185, 

206 
infectious, 83, 249 
bacilli in, 83 
calomel in, 252 
case illustrating, 85, 136 
dysentery type, 84 
diet in, 84 
treatment, 84 
reaction to food in, 251 
stools in, 251 
treatment, 251 
mechanical, 77 
nervous, 77 
of infancy, 76 
starvation in, 88 
summer, 78 
types of, 208, 209 
whey of cow's milk in, 207 
Diet in constipation, 74 
in fermentative diarrhea, 80 



372 



INDEX 



Diet in infectious diarrhea, 84 
in pyloric spasm, 94 
in pyloric stenosis, 92 
list at thirteen months, 55 

Children's Hospital, Boston, 

54 
for eighteen months' baby, 

54 
sixteen to eighteen months, 55 
twenty to twenty-two months, 
55 
of nursing mother, 24 
Difference between cow's milk and 

breast milk, 155 
Difficult feeding cases, 59 
Digestion, disturbances of, 61 
of different food elements, 20 
of milk, 163. See also Milk, di- 
gestion of. 
Disaccharid, 20, 165 
Disturbances in breast-fed, 280 
of digestion, 61 

too much food as cause, 61 
of nutrition, modern conception 
of, 178 
Drugs in constipation, 74, 203 
in diarrhea, 81, 86 
in spasmophilia, 114 
Dysentery, 83 
treatment, 253 
dietetic, 253 

Frank, for infection with true, 
253, 254 
Dyspepsia, 209 
causes, 211 

in disturbances of breast-fed, 288 
metabolism in, 210 
starvation in treatment of, 210, 

212 
states of, 205 
treatment of, 212 
weight curve in, 213, 214, 215 
whey in, .207 



Eggs, 53 

Eisenzucker, 74 

Eiweiss, 48, 64, 219 

Electrical reactions in diagnosis of 

spasmophilia, 113 
End-products in intestine, 20, 21 
Enemas, 75 

suds, 26 
Energy of foods, 176 
Enteral and parenteral infections, 

242 
Eskay's Food, 50, 52 
Evaporated milks, 51, 52 

Failure to gain, 193 

carbohydrates in, 199, 200 
constipation in, 194, 195 
diagnosis, 201 
disturbed balance in, 200 
milk injury in, 194 

case illustrating, 194 
treatment, 201 
Fat, absorption of, 20 

caloric production of, 21, 176 
digestion of, 20, 164 
in milk, 153 

Babcock's quantitative test for, 
154 
in stool, 164 
indigestion, acute, 61 
chronic, 61 
stools in, 71 
symptoms, 25 
intolerance, case illustrating, 68 
in older children, 67 
treatment, 62 

in older children, 67 
scrambled-egg stool type, 63 
soapy stool type, 62 
neutral, 20, 164 
of cow's milk, 156 
percentage of, for normal infant, 
. 43 



INDEX 



373 



Fat, test for, in stools, 72 
Fat-soap stools, 195 
Fat- soaps, 164 
Fatty acid, 20, 164 
Feces, 173. See also Stools. 
Feeding, percentage, 17, 18 
Fermentation, 157, 174, 199 
Food, caloric value of, formula for 
calculating, 40 
composition of, 42 
different elements of, 43 
digestion of, 20 
fat, 43 

milk, 18, 153 
protein, 46 
starch, 45 
sugar, 44 
table for normal infant, 42 
Foods, energy of, 176 
malted, 44, 45, 50 
proprietary, 49 
solid, for infant, 53 
Frank treatment for infection, with 

true dysentery, 253, 254 
Fruit, 54 



Gas bacillus in diarrhea, 83 
Globulins, 153 
Glucose, 165 



Harrison's grooves, 106 
HorJick's Malt Food, 212, 236 

Malted Milk, 50, 52 
Hunger in alimentary intoxication, 
218 

in decomposition, 227, 231 

in dyspepsia, 210, 212 



Ileocolitis, 83 
Imperial Granum, 50, 52 



Inanition, 284 

Indigestion, chronic sugar and fat, 
case illustrating, 125 
fat, acute, 61 
chronic, 61 
from nervous influences, case illus- 
trating, 118 
in older children, 67 
protein, acute, 65 

chronic, 66 
starch, chronic, 66 
sugar, acute, 64 

chronic, 65 
too much food as cause, 61 
various types, 59 
Infant, normal, feeding of, 41 
premature, 56-58 
Welfare Society, 267 
Infections, parenteral and enteral, 
242 
anorexia in, 248 
as cause of increased intestinal 

fermentation, 244 
diagnosis, 245 
treatment, 245 
vomiting in, 247 
Infectious diarrheas, 249. See also 

Diarrheas, Infectious. 
Intestinal antiseptics in diarrhea, 

82,87 
Intestine, acidity in, 20, 21 
alkalinity in, 20, 21 
bacteria in, 20, 208 
end-products in, 20, 21 
Intoxication, alimentary, 214 
diagnosis, 217 
treatment, 218 

in older children, 223 
states of, 205 
whey in, 207 
Intussusception, cases illustrating, 
96,97 
definition, 95 



374 



INDEX 



Intussusception, stools in, 95 

treatment, 96 

tumor in, 95 
Iron, 68, 73 

Keller's Malt Soup, 195, 200, 281 
Kindolac, 50, 53 

Lactagogue, 272 
Lactic acid, 153 

bacillus, 49 

milk, 49 
Lactose, 44, 153 
Larosan, 48 

Laxatives in constipation, 74 
Lime-water, 33,47, 48 
Loeflund's Malt Soup Extract, 45 



Magnesia, milk of, 75 
Magnesium, 164 
Malt soup extract, 203 
Malted foods, 44, 45, 50 
Maltine Malt Soup, 45 
Maltose, 44, 45, 165 
Malt-sugar, 44, 45 
Meade's Dextri-maltose, 45 
Meconium, decomposition of, 22 
Mellin's Food, 45, 50, 52, 212, 236 
Metabolism of salt, 169 

of water, 171 
Milk, 152 

adulteration of, 154 
Babcock test, 154 

albumin in, 19 

bacterial growth in, 156 

boiled, 160, 162, 250, 254, 255 

breast, 23. See Breast milk. 

casein in, 19 

certified, 27, 159 

composition of, 19, 153 
breast, 155 



Milk, composition of cow's, 155 
cow's, breast, difference between, 
155 

digestibility of, 20 

protein in, 46 
digestion of, 163, 171 

carbohydrates in, 165 

fat in, 164 

protein in, 163 

salts in, 169 

sugars in, 165 
evaporated, 51, 52 
food elements of, 18 
homogenized, 44 
in gastro-intestinal tract, 171 
injury, Czerny's, case illustrating, 

194 
lactic acid, 49 
mineral matter in, 168 
modification of, 31. See also 

Modification of milk. 
of magnesia, 75 
pasteurized, 28, 159 
proteins in, 19 
skimmed, composition of, 32 
sterilized, 28, 29 
sugar of, 20, 44, 153 
whole, composition of, 38 
Milk-borne diseases, 157 
Mineral matter in baby's food, 168 
Modern conception of disturbances 

of nutrition, 178 
Modification of milk, 29, 30, 31-40 

gravity method, 31, 32 

long method, 33 

preparation of formula, 32, 33 

short method, 35 

sugar table for, 36 

whole method, 37 



Nervous influences, indigestion 
from, case illustrating, 118 



INDEX 



375 



Neutral fat, 20 

New-born baby, bowels of, 22 

first feeding of, 22 
Nipples, erosions and fissures of, 

medicaments for, 271 
Normal infant, feeding of, 41 
artificial, 256 
interval for, 257 
methods of Middle West, 

260 
prophylactic method, 260 
diet lists, 54, 55 
fat percentage in, 43 
food table for, 42 
fruit in, 54 
intervals for, 42 
night feedings, 43 
number of, 42 
olive oil in, 44 
protein in, 46 
solid food, 53 
sugar in, 44, 45 
twenty-four-hour amount, 42 
vegetables in, 54 
Nurse, wet-, qualifications of, 27 
Nurses, 268 

Nursing, breast. See Breast feeding. 
mother, care of, 21 
diet of, 24, 278 
fluid for, 278 
menstruation of, 26 
nervous, 26 
pregnancy in, 26 
Nutrition, disturbances of, bacterio- 
logical classification, 180 
Czerny's etiological classifica- 
tion, 181 
diagnosis, 190 
fat injury in, 181 
Finkelstein's classification of 
food disturbances, 184, 185 
latest classification, 189 
milk injury in, 181 



Nutrition, disturbances of, modern 
conception of, 178 
pathological classification, 179 
secondary, due to parenteral in- 
fections, 243, 244 
starch injury in, 181 
sugar injury in, 185 
Vienna conception of, 178, 179 
weight curve in, 183, 186, 192 
Nutritional disturbances of breast- 
fed baby, 25, 26 
Nux vomica, 68, 73 

Oatmeal jelly, 46 

Olive oil, 44 

Opium in diarrhea, 81, 87 

Orange-juice, 28, 29, 53, 54, 160 

in treatment of scurvy, 110 
Overfeeding, 288, 289 

Pancreatic juice, 20 

Parenteral and enteral infections, 

242 
Pasteurization, 158 
Pasteurized milk, 28 
Peptonization of milk, 47 
Percentage feeding, 17, 18, 259 

calculation of formulae, 34 

principles of, 89, 90 
Peristalsis, increased causes of, 76 
Phenolphthalein, 75 
Pigeon-breast, 106 
Potato, 54 
Premature babies, 56-58 

breast milk for, 56 

cow's milk for, 57 

indigestion of, 58 

water for, 58 
Proprietary foods, 49 
Protein, absorption of, 20 
caloric production of, 21, 176 
content of breast milk, 155 

of cow's milk, 155 



376 



INDEX 



Protein, digestion of, 20, 163 
in food for normal infant, 46 
in milk, 19, 153 
in urine, 164 
indigestion, acute, 65 
chronic, 66 
stools, in 66, 72 
symptoms, 25 
Prune-juice, 53 

Purgatives in diarrhea, 81, 86 
Putrefaction, 157, 174, 199 
Pyloric spasm, definition, 91, 93 
physical signs of, 93 
treatment, 94 
stenosis, definition, 91 
symptoms, 91 
treatment, 92 
Pylorospasm, 93 

Rachitis, 104. See also Rickets. 
Rickets, 104 

acute, case illustrating, 139 

causes, 105 

definition, 104 

general appearance, 106 

pathology, 104 

symptoms, 105 

treatment, 106 
Ridge's Food, 50 

Saccharated oxid of iron, 74 
Saccharose, 165 
Salt metabolism, 169 
Salts, digestion of, 169 

in breast milk, 156 

in cow's milk, 156 

in milk, 20, 153 

in stool, 169 

of amino-acids, 20 

relation of, to water in body, 171 
Scrambled-egg stools, 62, 63, 71 
Scurvy, 28, 29 



Scurvy, diagnosis, 109 

pathology, 108 

symptoms, 109 

treatment, 110 

vitamins in, 107 
Skimmed milk, 32 
Soap in intestine, 20 

in stool, 20 

stools, 62, 63, 71 
Soaps, fat-, 164 
Sodium bicarbonate, 47, 48 

bromid in diarrhea, 87 

citrate, 47, 48 
Spasmophilia, definition, 111 

diagnosis, 112, 113 

etiology, 111 

prognosis, 113 

treatment, 114 

Trousseau's symptom in, 113 
Starch in food for normal infant, 45 

indigestion, chronic, 66 
stools in, 66, 72 

intolerance in older children, 70 

test for, in stools, 73 
Starvation, 59 

in treatment of alimentary in- 
toxication, 218 
of dyspepsia, 210, 212 
Sterilized milk, 28, 29 
Stomach, digestion in, 20 
Stools, 173 

abnormal, types of, 71 

bacteria in, 173 

curds in, 160 

fat in, 164 

in constipation, 74 

in decomposition, 226, 227 

in disturbances in breast-fed, 281- 
283 

in fat indigestion, 71 

in fermentative diarrhea, 78 

in infancy, 70 

in infectious diarrheas, 251 



INDEX 



377 



Stools in protein indigestion, 66, 72 

in starch indigestion, 66, 72 
intolerance, 70 

in sugar indigestion, 72 

microscopic examination of, 72 

oily, 71 

of breast-fed baby, 25 

salts in, 169 

scrambled-egg, 62, 63 

secondary products in, 175 

soapy, 62, 63, 71 

unabsorbed foodstuffs in, 174 
Streptococcus bacillus in diarrhea, 

83 
Sucrose, 44 
Suds enema, 26 
Sugar, 44 

absorption of, 20 

caloric production of, 21 

child's need of, 166, 167 

complex, 20 

diet, high, as cause of diarrhea, 
185,206 

digestion of, 20, 165 

forms of, 165 

in food for normal infant, 44 

in stools, 20 

indigestion, acute, 64 
chronic, 65 
stools in, 66, 72 

of milk, 20, 44, 153 

relation of, to temperature, 168 

table, 36 
Suppositories, 75 



Temperature, relation of sugars to, 
168 

Tetany, 111. See also Spasmophilia. 

Toasted bread, 53 

Toxic absorption, 22 

Trousseau's symptom in spasmo- 
philia, 113 



Undernourishment of breast-fed 

baby, 25, 26 
Urine, acetone in, 99 

diacetic acid in, 99 

in acidosis, 100 

protein in, 164 

Vegetables, 54 

Vitamins, absence of, as cause of 

scurvy, 107 
Vomiting from irregular feeding, 
case illustrating, 116 

in disturbances of breast-fed, 280 

obstinate, from feeding too 
quickly, case illustrating, 121 

projectile, 91 

recurrent, acetone in urine in, 100 

Water and carbohydrates, 167 

barley, 45 

content of whole milk, 38 

gain in weight from, 167 

in body, relation of salts to, 171 

in milk, 154 

metabolism, 171 

supply in inanition, 288 
Weaning, 26 

Weight curve in nutritional dis- 
turbances, 183 
in parenteral infections, 245 

gain in, from water, 167 

in disturbances of nutrition, 186 

of normal breast-fed baby, 24 
Wet-nurse, qualifications of, 27 
Whey, composition of, 46 

in dyspepsia, 207 

in intoxication, 207 

of cow's milk, in nutritional dis- 
turbance, 206, 207 

preparation of, 47 
Whole milk, 38 

Zwieback, 53 



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School. Octavo of 417 pages, with 329 text-illustrations and 3 
colored plates. Cloth, $6.5° net. 

ORIGINAL TECHNIC 

This book presents Dr. Albee's original applied technic for bone-graft 
work. The successful outcome of any procedure to restore the skeletal archi- 
tecture depends not only upon a proper operative technic, but in many cases 
in a greater degree upon the skill with which the postoperative external fix- 
ation dressing is applied and in the convalescent management of the case. 
Dr. Albee here gives you his own successful technic and his own methods of 
dressing and management, all illustrated with original pictures. This is the 
only book going fully into this important question of bone surgery, a field 
that is attracting pronounced attention over the entire surgical world. 



Smithies and Ochsner's 
Cancer of the Stomach 

Cancer of the Stomach. By Frank Smithies, M. D., 
Gastro-enterologist to Augustana Hospital, Chicago. With a chap- 
ter on the Surgical Treatment of Gastric Cancer by Albert J. 
Ochsner, M. D., Professor of Clinical Surgery, University of 
Illinois. Octavo of 525 pages, illustrated. Cloth, $5.75 net. 

RECENTLY ISSUED 

This work gives you the information gleaned from a study of 921 oper- 
atively and pathologically demonstrated cases of gastric cancer. 

It is the first complete monograph upon this subject for more than a 
decade, and represents some ten years' study.' 

The wonderful advances made within this time are of the greatest importance 
to the clinician, the pathologist, and the surgeon. Dr. Smithies presents 
these advances in a most practical way. The chapter on Operative Treat- 
ment, by Dr. Ochsner, gives you the most approved and successful technic^ 
illustrating the various operations with original pictures. 



SUHGERY AND ANATOMY 



Hornsby and Schmidt's 
The Modern Hospital 

The Modern Hospital. Its Inspiration ; Its Construction; 
Its Equipment ; Its Management. By John A. Hornsby, M. D., 
Secretary, Hospital Section, American Medical Association ; and 
Richard E. Schmidt, Architect. Large octavo of 644 pages, 
with 207 illustrations. Cloth, 37.00 net; Half Morocco, $8.50 net. 

ADOPTED AT ONCE BY THE U. S. GOVERNMENT AS "THE LAW" 

"Hornsby and Schmidt" tells you just exactly how to plan, construct, 
equip, and manage a hospital in all its departments, giving you every detail. 
It gives vou exact data regarding heating, ventilating, plumbing, refrigerating, 
etc.— and the costs. It tells you how to equip a modern hospital with modern 
appliances. It tells you what you need in the operating room, the wards, the 
private rooms, the dining room, the kitchen — every division of hospital house- 
keeping. It gives you definite diets for the patients and the hospital house- 
hold. It gives you hundreds of valuable points on the business management 
of hospitals — large and small. 



Allen's Local Anesthesia 

Local Anesthesia. By Carroll W. Allen, M. D., In- 
structor in Clinical Surgery at Tulane University of Louisiana. 
Octavo of 625 pages, illustrated. Cloth, $6.00 net. 

ILLUSTRATED 

This is a complete work on this subject. You get the history of local 
anesthesia, a chapter on nerves and sensation, giving particular attention to 
pain — what it is and its psychic control. Then comes a chapter on osmosis 
and diffusion. Each local anesthetic is taken up in detail, giving very special 
attention to cocain and novocain, pointing out the action on the nervous system, 
the value of adrenalin, paralysis caused by cocain anesthesia, control of tox- 
icity. You get Crile's method of administering adrenalin and salt solution, 
the exact way to produce the intradermal wheal, to pinch the flesh for the inser- 
tion of the needle — all shown you step by step. You get an article on anoci- 
association, the production of local anesthesia in the various regions, spinal 
analgesia, and epidural injections. There is a large section on dental anesthesia. 



SAUNDERS' BOOR'S ON 



Moynihan's Abdominal Operations 

Abdominal Operations. By Sir Berkeley Moynihan, M. S. (Lon- 
don), F. R. C. S., of Leeds, England. Two octavos of 500 pages each, 
with 385 illustrations, 5 in colors. Per set: Cloth, $11.00 net. 

THIRD EDITION, RESET 

This new edition has been issued after a most thorough revision — so thorough that 
the work had to be reset and issued in two handsome volumes. Over 150 pages of 
new matter and 80 new illustiations were added. Two new chapters are those on 
excision of gastric ulcer and complete gastrectomy. Some 95 illustrative cases are dis- 
tributed throughout the work, giving every detail, history, examination, operation, 
complications, results. These are extremely instructive. Moynihan's definite, 
didactic style, together with the large number of practical illustrations and the 
illustrative cases make this work the most useful abdominal surgery published. 
Each volume has stamped on its back the subjects treated therein, thus facilitating 
quick consultation. 



Moynihan's Duodenal Ulcer iS! 

Duodenal Ulcer. By Sir Berkeley Moynihan, M. S. (Lon- 
don), F. R. C. S., of Leeds, England. Octavo of 486 pages, illus- 
trated. Cloth, $5.00 net. 

" Easily the best work on the subject ; coming, as it does, from the pen of one of 
the masters of surgery of the upper abdomen, it may be accepted as authoritative." 
— The London Lancet. 



Moynihan on Gall-stones SSSSn 

Gall-stones and Their Surgical Treatment. By Sir Berkeley 
Moynihan, M. S. (London), F. R. C. S. Octavo of 458 pages, illus- 
trated. Cloth, $5.00 net. 

" He expresses his views with admirable clearness, and he supports them by a 
large number of clinical examples, which will be much prized by those who know 
the difficult problems and tasks which gall-stone surgery not infrequently presents." 
— British Medical Journal. 



SURGERY AND ANATOMY 



Crandon and Ehrenfried's 
Surgical After-treatment 

Surgical After=treatment. By L. R. G. Crandon, M. D., 
Assistant in Surgery, and Albert Ehrenfried, M. D., Assistant 
in Anatomy, Harvard Medical School. Octavo of 831 pages, 
with 265 original illustrations. Cloth, $6.00 net. 

THE NEW (2d) EDITION 

This worK tells how best to manage all problems and emergencies of sur- 
gical convalescence from recovery-room to discharge. It gives all the details 
completely, definitely, yet concisely, and does not refer the reader to some 
other wont perhaps not then available. The postoperative conduct of all 
operations ; s given. There is an elaborate chapter on Vaccine Therapy, Im- 
munization by Inoculation, and Specific Sera, by Dr. George P. Sanborn. 
Therapeutic Gazette 

" This book is one which can be read with profit by the active surgeon and practitioner 
and will be generally commended." 



Mayo Clinic Papers 

Mayo Clinic Papers. By William J. Mayo, M. D., 
Charles H. Mayo, M. D., and their Associates at The Mayo 
Clinic, Rochester, Minn. Papers of 1905-09, 1910, 191 1, 1912, 
1913. Each, $5.50 net. Papers of 1916 preparing. 



A Collection of Papers (published previous to 1909). By 
W. J. and C. H. Mayo. Two octavos of 525 pages each, illus- 
trated. Per set: Cloth, $10.00 net. 



SAUNDERS' BOOKS ON 



Keen's New Surgery 

Surgery ; Its Principles and Practice. Written by 82 
eminent specialists. Edited by W. W. Keen, M. D., LL. D., 
Hon. F. R. C. S., Eng. and Edin., Emeritus Professor of the 
Principles of Surgery and of Clinical Surgery at the Jefferson 
Medical College, Philadelphia. Six large octavo volumes of 
over 1050 pages each, containing 3100 illustrations, 157 in colors. 
Per volume : Cloth, $7.00 net; Half Morocco, $8.00 net. 

VOLUME VI GIVES YOU THE NEWEST SURGERY 

In this sixth volume you get all the newest surgery — both general and 
special — from the pens of those same international authorities who have made 
the success of Keen's Surgery world-wide. Each man has searched for the 
new, the really useful, in his particular field, and he gives it to you here. 
Here you get the newest surgery, and fully illustrated. Then, further, you 
get a complete index to the entire six volumes, covering 125 pages, but so 
arranged that reference to it is extremely easy. If you want the newest sur- 
gery, you must turn to the new " Keen " for it. 



Moorhead's 
Traumatic Surgery 

Traumatic Surgery. By John J. Moorhead, M. D., 
Adjunct Professor of Surgery, New York Post-Graduate Medical 
School and Hospital. Octavo of 760 pages, with 520 original 
line-drawings. Just Ready. Cloth, $6.50 net. 

WITH 522 ORIGINAL LINE-DRAWINGS 

This work has a wide appeal. It appeals to the surgeon, the prac- 
titioner, the mining, railroad, and industrial physician, those having to do 
with Compensation Law, accident insurance and claims, and legal medicine. 
But its greatest appeal is to the general practitioner — the man in general prac- 
tice anywhere — because practically the entire work is devoted to Minor Sur- 
gery — those traumatic conditions that form a part of every doctor's daily prac- 
tice. The work is original in text, illustrations, arrangement, and method of 
presentation. Only those treatments are given which Dr. Moorhead has 
found successful. 



SURGE R Y AND ANA TO MY 



Scudder's Fractures 

WITH NOTES ON DISLOCATIONS 



The Treatment of Fractures : with Notes on a few Com- 
mon Dislocations. By Charles L. Scudder, M. D., Surgeon to 
the Massachusetts General Hospital, Boston. Octavo volume of 
735 P a g es > w i tn io 57 illustrations. Polished Buckram, $6.00 net. 

THE NEW (8th) EDITION, ENLARGED 

OVER 35,000 COPIES 

Seven large editions of this remarkable book is a decisive indication 
of the value of Dr. Scudder's work. For this new edition numerous ad- 
ditions have been made throughout the text and a large number of new 
illustrations added, greatly enhancing the value of the work. In every way 
this edition reflects the very latest advances in the treatment of fractures. 
J. F. Binnie, M. D., formerly University of Kansas. 

" Scudder's Fractures is the most successfnl book on the subject that has ever been 
published. I keep it at hand regularly." 



Scudder's Tumors of the Jaws 

Tumors of the Jaws. By Charles L. Scudder, M. D., 
Surgeon to the Massachusetts General Hospital, Boston. Octavo 
of 395 pages, with 353 illustrations, 6 in colors. Cloth, #6.50 net. 

WITH NEW ILLUSTRATIONS 

Dr. Scudder in this book tells you how to determine in each case the 
form of new growth present, and then points out the best treatment. As the 
tendency of malignant disease of the jaws is to grow into the accessory sinuses 
and toward the base of the skull, an intimate knowledge of the anatomy of 
these sinuses is essential. Dr. Scudder has included, therefore, sufficient 
anatomy and a number of illustrations of an anatomic nature. Whether gen- 
eral practitioner or surgeon, you need this new book because it gives you just 
the information you want. 



SAUNDERS' BOOKS ON 



Cotton's 
Dislocations and Joint Fractures 



Dislocations and Joint Fractures. By Frederic Jay 
Cotton, A. M., M. D., First Assistant Surgeon to the Boston 
City Hospital. Octavo volume of 654 pages, with 1201 original 
illustrations. Cloth, $6.00 net. 

TWO PRINTINGS IN EIGHT MONTHS 

Dr. Cotton's clinical and teaching experience in this field has especially 
fitted him to write a practical work on this subject. He has written a book 
clear and definite in style, systematic in presentation, and accurate in state- 
ment. The author is himself the artist, so that the illustrations show just 
those points he wished to emphasize. 

Boston Medical and Surgical Journal 

"The work is deliehtful. spirited, scholarly, and original. It brings the subjects up 
to date — a feat long neglected." 



Elsberg's 
Surgery of Spinal Cord 

Diagnosis and Treatment of Surgical Diseases of the 
Spinal Cord and its Membranes. Octavo of 330 pages, with 
158 illustrations, 3 of them in colors. By Charles A. Elsberg, 
M. D., Professor of Clinical Surgery, New York University and 
Bellevue Hospital Medical School. Cloth, $5.00 net. 

INCLUDING USE OF X-RAYS 

There is no other book published like this by Dr. Elsberg. It gives you 
in clear definite language the diagnosis and treatment of all surgical diseases 
of the spinal cord and its membranes, illustrating each operation with original 
pictures. Because it goes so thoroughly into symptomatology, diagnosis, and 
indications for operation this work appeals as strongly to the general prac- 
titioner and neurologist as to the surgeon. The first part of the work is de- 
voted to anatomy and physiology of the spinal cord, and to the symptomatology 
of surgical spinal diseases. The second part takes up operations upon the 
spine, the cord, and nerve-roots. The third part is given over to surgical dis- 
eases of the cord and its membranes — their diagnosis and treatment. In- 
cluded also are chapters on hematomyelia and spinal gliosis, because in these 
diseases much harm is done to the fiber tracts by compression. 



SURGER Y AXD AXA TOMY 



Kelly and Noble's Gynecology 
and Abdominal Surgery 

Gynecology and Abdominal Surgery. Edited by Howard 
A. Kelly, M. D., Professor of Gynecology in Johns Hopkins 
University; and Charles P. Noble, M. D., formerly Clinical 
Professor of Gynecology, Woman's Medical College, Philadel- 
phia. Two imperial octavos of 950 pages each, with 880 illustra- 
tions. Per volume : Cloth, $8.00 net ; Half Morocco, $9.50 net. 

WITH 880 ILLUSTRATIONS BY BECKER AND BRODEL 

This work possesses a number of valuable features not to be found in any 
other publication covering the same fields. It contains a chapter upon the 
bacteriology and one upon the pathology of gynecology, and a large chapter 
devoted entirely to medical gynecology, written especially for the physician 
engaged in general practice. Abdominal surgery proper, as distinct from 
gynecology, is fully treated, embracing operations upon the stomach, intes- 
tines, liver, bile-ducts, pancreas, spleen, kidneys, ureter, bladder, and peri- 
toneum. 

American Journal of Medical Sciences 

"It is needless to say that the work has been thoroughly done ; the names of the 
authors and editors would' guarantee this, but much may be said in praise of the method 
of presentation ; and attention may be called to the inclusion of matter not to be found 
elsewhere." 



Crile and Lower's Anoci-Association 

Anoci-Association is the new way of anesthetizing. It pre- 
vents shock, it robs surgery of its harshness, it diminishes post- 
operative mortality, it lessens the likelihood of nausea, vomit- 
ing, gas-pains, backache, nephritis, pneumonia, and other post- 
operative complications. You get anoci-association and blood- 
pressure and the technic of nitrous-oxid oxygen anesthesia. 

Octavo of 275 pages, illustrated. By George W. Crile, M. D., Professor of Surgery, 
and William E. Lower, If. D., Associate Professor of Genito-Urinary Surgery, Western 
Reserve University. Cloth, $3.00 net. 



•° SAUNDERS' BOOKS ON 

Mumford's 
Practice of Surgery 

The Practice of Surgery. By James G. Mumford, M. D., 
formerly Lecturer on Surgery, Harvard Medical School. Octavo 
of 1032 pages, with 683 illustrations. Cloth, $7.00 net. 
SECOND EDITION 

This is a clinical surgery, giving those methods and operations which the 
author has personally followed for the past twenty years. The plan of the 
work is somewhat off the conventional lines, the diseases being taken up in 
Iheir order of interest, importance, and frequency. 

John B. Murphy, M. D., Northwestern Medical School, Chicago 

" This work truly represents Dr. Mumford's intellectual capacity and scope, and pre- 
sents in a terse, forceful, yet pleasing manner, the live surgical topics of the day. It is in 
every particular up to date." 



DaCost&'s Modern Surgery 

Modern Surgery — General and Operative. By John 
Chalmers DaCosta, M. D., Samuel D. Gross Professor of Sur- 
gery, Jefferson Medical College, Philadelphia. Octavo of 15 15 
pages, with 1085 illustrations. Cloth, $6.00 net; Half Morocco, 
$7.50 net. 

SEVENTH EDITION 

A surgery, to be of the maximum value, must be up to date, must be com- 
plete, must have behind its statements the sure authority of experience, must 
be so arranged that it can be consulted quickly ; in a word, it must be practical 
and dependable. Such a surgery is DaCosta' s. Always an excellent work 
for this edition it has been very materially improved by the addition of much 
new matter and many additional illustrations. 

Rudolph Matas, M.D., Professor of Surgery , Tulane University of Louisiana. 

" This edition is destined to rank as high as its predecessors, which have placed the 
learned author in the fore of text-book writers. The more I scrutinize its pages the more I 
admire the marvelous capacity of the author to compress so much knowledge in so small » 
space." 



SURGERY AND ANATOMY 



Cullen's 
Diseases of the Umbilicus 

Embryology, Anatomy, and Diseases of the Um= 
bilicus ; together with Diseases of the Urachus. By Thomas 
Stephen Cullen, M. B., Associate Professor of Gynecology in 
the Johns Hopkins University. 8vo of 680 pages, with 269 illus- 
trations. Cloth, $7.50 net; Half Morocco, $9.00 net. 

ILLUSTRATED BY MAX BRODEL 

This new monograph appeals to the anatomist, pediatrician,, surgeon, 
genito-urinary specialist, and practitioner. Conditions of the umbilicus 
have always been more or less the "X" of general practice. This book ex- 
plains these unknown conditions, presenting thoroughly every disease in 
any way associated with the umbilicus, and making the entire subject 
strikingly clear. 



Crile's The Kinetic Drive Recently issued 

The Kinetic Drive. By George W. Crile, M. D., Professor of 
Surgery, Western Reserve University, Cleveland. Octavo of 71 pages, 
illustrated. Cloth, $2.00 net. 

In this book Dr. Crile analyzes the mechanism by which the present-day industrial 
and commercial "speeding" is accomplished, and relates it to the speeding due toother 
stimuli, such as infections, auto-intoxication, physical injury, etc. The work is timely. 

Montgomery's Care of Surgical Patients 

Care of Patients: Before, During, and After Operation. By E. 
E. Montgomery, M. D., LL. D., Professor of Gynecology in Jefferson 
Medical College. 12 mo of 149 pages, illustrated. Cloth, $1.25 net. 

This book gives you many hints and suggestions acquired during many years of 
operative work. Its use will lessen the anxiety of the surgeon, promote better work, 
facilitate the labor of nurses and interns, and add to the comfort and satisfaction of 
the patient. 

Rad&sch's Anatomy Ready soon 

Manual of Anatomy. By Henry E. Radasch, M. D., Assistant 
Professor of Histology and Biology, Jefferson Medical College. Octavo 
of 500 pages, profusely illustrated. 

Dr. Radasch's new handbook is complete in both text and illustrations. Every 
effort has been taken to make the study of anatomy both easy and interesting the 
many illustrations contributing markedly to this end. 



SAUNDERS' BOOKS ON 



Cushing's Tumors of the Brain S7Z 

Tumors of the Nervus Acusticus and the Syndrome of 
the Cerebellopontine Angle. By Harvey Cushing, M. D., 
Surgeon-in-Chief, Peter Bent Brigham Hospital, Boston. 
Octavo of 350 pages, fully illustrated. 

A FULLY ILLUSTRATED STUDY 

Dr. Cushing presents here an exhaustive study of tumors of the acoustic 
nerve. He gives you his own technic, and the results of study and ob- 
servation of some thirty cases. These tumors, despite the fact that they 
are comparatively common, are imperfectly understood, and the present 
volume is a thorough presentation of the subject, embracing history, ana- 
lysis of symptoms, physical examination, morphology, histology, and opera- 
tive technic — in short, every aspect of the cases clearly and completely 
covered. You are given not only the surgical aspects, but the historical, 
symptomatic, and pathologic as well. The illustrations are particularly 
noteworthy; they are plentiful, practical, and definitely valuable. Many 
show the successive steps in operation, demonstrating as nothing else can 
the exact technic that makes for the successful outcome. 



Owen's Treatment of Emergencies out 

The Treatment of Emergencies. By Hubley R. Owen, 
M. D., Surgeon to the Philadelphia General Hospital. i2mo 
of 560 pages, with 249 illustrations. 

A COMPLETE TREATMENT 

Dr. Owen's book gives you not only the actual technic of the pro- 
cedures, but, what is equally important, the underlying principles of the 
treatments, and the reason why a particular method is advised. You get 
chapters on fractures of all kinds, going fully into symptoms, treatments, 
and complications. You get treatments of contusions, of wounds, both 
lacerated and incised. Particularly strong is the chapter on gun-shot 
wounds, which gives the new treatments that the great European War has 
developed. You get the principles of hemorrhage, together with its con- 
stitutional and local treatments. You get chapters on sprains, disloca- 
tions, burns, sunburn, chilblain, asphyxiation, convulsions, hysteria, apo- 
plexy, exhaustion, opium poisoning, uremia, and electric shock. You get 
sections on bandages, and a complete discussion of artificial respiration, 
including mechanical devices. The book is complete; it is thorough; it is 
practical. 



SURGERY AND ANATOMY 13 

Dannreuther's Emergency Surgery 

Minor and Emergency Surgery. By Walter T. Dannreuther, 
M. D., Surgeon to St. Elizabeth's Hospital and to St. Bartholomew's 
Clinic, New York City. i2mo of 225 pages, illustrated. Cloth, $1.25 
net. 

Fowler's Operating Room Thi ' d Edition 

The Operating Room and the Patient. By Russell S. Fowler, 
M. D., Chief Surgeon, First Division, German Hospital, Brooklyn, New 
York. Octavo of 611 jjages, illustrated. Cloth, $3.50 net. 

Keen's Addresses and Other Papers 

Addresses and Other Papers. Delivered bv William W. Keen. 
M. D., LL.D., F. R. C. S. (Hon.), Professor of the Principles of Surgery 
and of Clinical Surgerv. Jefferson Medical College, Philadelphia. Octavo 
volume of 441 pages, illustrated. Cloth, $3.75 net. 

Keen on the Surgery of Typhoid 

The Surgical Complications and Sequels of Typhoid Fever. 
By Wm. W. Keen, M. D., LL.D., F. R. C. S. (Hon.), Professor of 
the Principles of Surgery and of Clinical Surgery, Jefferson Medical 
College, Philadelphia, etc. Octavo volume of 386 pages, illustrated. 
Cloth, $3.00 net. 

American Text-Book of Surgery Fourth Edition 

American Text- Book of Surgery. Edited by W. W. Keen, M. D., 
LL. D., Hon. F. R. C. S., Eng. and Edin.; and J. William White, 
M. D., Ph. D. Octavo, 1363 pages, 551 text-cuts and 39 colored and 
half-tone plates. Cloth, $7.00 net ; Half Morocco, $8.50 net. 

Nancrede's Essentials of Anatomy 8th Edition 

Essentials of Anatomy, including the Anatomy of the Viscera. 
By Charles B. Nancrede, M. D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Crown octavo, 430 
pages, 155 cuts. Based on Gray's Anatomv. Cloth, Si. 25 net. In 
Saunders' Question Compends. 

Whiting's Bandaging Recently Issued 

This new work, takes up each bandage in detail, telling you — and 
shriving you by original illustrations — just how each bandage should be 
applied, each turn made. Dr. Whiting's teaching experience has 

enabled him to devise means for overcoming common errors in applying 
bandages. 

i2mo of 151 pages, with 117 illustrations. By A. D. Whiting. M. D.. Instructor in 
Surgery at the University of Pennsylvania. Cloth, Ji.as net. 



14 SAUNDERS' BOOKS ON 

American Illustrated Dictionary New (gth) EdWon 

The American Illustrated Medical Dictionary. With 
tables of Arteries, Muscles, Nerves, Veins, etc. : of Bacilli 
Bacteria, etc. ; Eponymic Tables of Diseases, Operations, 
Stains, Tests, etc. By W. A. Newman Dorland, M. D. 
Large octavo, 1 137 pages. Flexible leather, $4.50 net; with 
thumb index, $5.00 net. 

Howard A. Kelly, M. D., Professor of Gynecology, Johns Hopkins 
"Dr. Borland's dictionary is admirable. It is so well gotten up and of 
such convenient size. No errors have been found in my use of it." 

Golebiewski and Bailey's Accident Diseases 

Atlas and Epitome of Diseases Caused by Accidents. 
ByDx. Ed. Golebiewski, of Berlin. Edited, with additions, 
by Pearce Bailey, M.D. Cloth, $4.00 net. In Saunders 7 
Hand- Atlas Series. 

Helferich and Bloodgood on Fractures 

Atlas and Epitome of Traumatic Fractures and Dislo- 
cations. By Prof. Dr. H. Helferich, o t Greifswald, Prussia. 
Edited, with additions, by Joseph C. Bloodgood, M.D., Asso- 
ciate in Surgery, Johns Hopkins University, Baltimore. 216 
colored figures on 64 lithographic plates, 190 text-cuts, and 
353 pages of text. Cloth, $3. 00 net. In Saunders' Atlas Series. 

Sultan and Coley on Abdominal Hernias 

Atlas and Epitome of abdominal Hernias. By Pr. Dr c 
G. Sultan, of Gottingen. Edited, with additions, by Wm c 
B. Coley, M.D. Cloth, $3.00 net. In Saunders' Hand- A tla^ 
Series. 

Fenger Memorial Volumes 

Collected Works of Christian Fenger, M. D. 
Edited by Ludwig Hektoen, M. D., Professor of Pathol- 
ogy, Rush Medical College, Chicago. Two octavos of 525 
pages each. Per set ; Cloth, $15.00 net. 

Zuckerkandl and DaCosta's Surgery f^^ 

Atlas and Epitome of Operative Surgery. By Dr. O. 
Zuckerkandl, of Vienna. Edited, with additions, by J. 
Chalmers DaCosta, M. D., Samuel D. Gross Professor of 
Surgery, Jefferson Medical College, Philadelphia. 40 col- 
ored plates, 278 text-cuts, and 410 pages of text. Cloth, 
$3.50 net. In Saunders* Atlas Series. 



SURGERY AXD ANATOMY 15 



Martin's Essentials of Surgery 7th Edition 

Essentials of Surgery. Containing also Venereal Diseases, Sur- 
gical Landmarks, Minor and Operative Surgery, and a complete des- 
cription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A. M., M. D., Professor of Clinical Surgery, 
University of Pennsylvania, etc. Crown octavo, 338 pages, illus- 
trated. With an Appendix on Antiseptic Surgery, etc. Cloth, Si. 25 
net. In Saunders' Question Compends. 

Metheny's Dissection Methods 

Dissection Methods and Guide. Octavo of 131 pages, illustrated. 
By David Gregg Metheny, M. D., L. R. C. P., L. R. C. S. (Edin.), 
L. F. P. S. (Glas. ), Associate in Anatomy at Jefferson Medical College, 
Philadelphia. Cloth, $1.25 net. 

American Pocket Dictionary New (9th} Editio; , 

The American Pocket Medical Dictionary. Edited by W. A. 
Newman Dorland, A.M., M.D. 693 pages. Full leather, limp, with 
gold edges, $1.25 net; with patent thumb index, $1.50 net. 



Bryan's Surgery 



Principles of Surgery. By W. A. Bryan, M. D.. Professor of 
Surgery and Clinical Surgery at Vanderbilt University, Nashville. 
Octavo of 667 pages, with 224 original illustrations. Cloth, $4.00 net. 

Dr. Bryan here discredits many fallacious ideas, giving you facts instead. He 
shows you in a most practical way the relations between surgical pathology and 
the resultant symptomatolgoy, and points out the influence such information has on 
treatment . 

Meyer & Schmieden's Bier's Hyperemic Treatment 

Second Edition 

Bier's Hyperemic Treatment in Surgery, Medicine, and the Special- 
ties. By Willy Meyer, M. D., Professor of Surgery, New York Post- 
Graduate Medical School and Hospital; and Prof. Dr. Victor SCHMIE- 
DEN, Assistant to Profess or Bier, University of Berlin, Germany. Octavo 
of 280 pages, illustrated. Cloth, $3oo net. 

Morris' Dawn of the Fourth Era in Surgery 

Dawn of the Fourth Era in Surgery and Other Articles. 
By Robert T. Morris, M. D., Professor of Surgery, New York Post- 
Graduate Medical School and Hospital. i2mo of 145 pages, illustrated. 
$ 1. 25 net. 



